Child & Adolescent Referral « Mental Health Cooperative

Referring Professional or Parent/Guardian*

Phone*

Child's Name*

School Name

Date of Birth*

Parent Guardian Name*

Parent/Guardian Phone*

Other Parent/Guardian Phone

Presenting Issues*

Symptoms

Has parent/guardian been notified that MHC will be contacting them regarding this referral?*

Yes
No

If referral is at least 16 y/o and chooses to initiate services without parent involvement, are you supportive?

Yes
No
N/A

Additional Comments

If you are a referring professional, do you request ongoing records on this client? (assuming release of information)

Yes
No

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.