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The following Referral and Release of Information are available to download in our Forms section, if you prefer to send by secure email or fax. The Release of Information is also included for download at the end of this page.

Online Referral

SAFETY IS OUR #1 PRIORITY

Please review our Services and Policies sections to carefully consider your client's needs in our level of care. Higher level of care is available and may be more appropriate for your client's success. We look forward to hearing from you and discussing any concerns. Thank you!


Who is making the referral?*

Email Address for Referral Source*

Phone Number for Referral Source*

Fax Number for Referral Source *

Client Full Name and Date of Birth*

Does your client receive benefits from SSA and/or DTA?*

Health Insurance Plan, Member ID, Group ID*

Primary Care Provider; Date of Last Physical Exam*

Medication Provider*

Pharmacy *

Casework, Therapeutic and Clinical Care Team and Activities*

Emergency Contact for Client*

Does your client have a Release of Information for all of the above contacts? *

Does your client meet criteria for supervised housing in a rest home? Please list your client's disabling medical, developmental, and/or psychiatric diagnoses that meet criteria for unskilled Level 4 Care.

Does you client have a physician's order to admit to Level 4 Care?

Does your client have a history of any of the following?*

Does your client take medication? *

Is your client current with seasonal Covid-19 and flu vaccinations? Please list vaccine type and date administered. 

Presenting Problem/Reason for Referral; Other helpful information*

The above Referral and Release of Information are 

available to download in our Forms section to send by secure email or fax.

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