Adult Referrals « Mental Health Cooperative

Referring Professional or Self-Referral Name*

Phone*

Client Name*

Date of Birth*

Client Phone*

Other Client Phone

Presenting Issues*

Symptoms

All MHC clients receive case management. Are additional services needed?

Counseling
Psychiatry
Medication-Assisted Treatment

Is the court involved with this individual/family and requiring feedback on progress and attendance?

Yes
No

Additional Comments

If you would like to save a copy of this submission for your records, please print this page with referral information BEFORE you submit to MHC. After printing the page, please submit the referral form to MHC’s intake department using the submit button below.