Child & Adolescent Referral Referring Professional or Parent/Guardian* Phone*Child's Name* School Name Date of Birth* MM slash DD slash YYYY Parent Guardian Name* Parent/Guardian Phone*Other Parent/Guardian PhonePresenting Issues*Symptoms Family conflict Does not follow adult directions School peer problems Cannot sit still and focus Is hyperactive - always on the go Is inattentive Poor impulse control Mood swings/tantrums Self-mutilation Alcohol or drug use Panic attacks or anxiety Obsessions/compulsions Aggression Depression/sadness 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 CommentsIf 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. Print this page