Child and Adolescent Mental Health Referral Form

Child and Adolescent Mental Health Referral Form

This form is to be completed with the intent to start the referral process to receive mental services for children and adolescents.

"*" indicates required fields

Name*
Address*
Is the parent/caregiver aware that child is being referred for therapy with Phoenix House?*
If not, please make sure to discuss with parent before submitting referral.
Symptoms and Behaviors*