Child and Adolescent Mental Health Referral Form

Child and Adolescent Mental Health Referral Form

Child and Adolescent Mental Health Referral Form

Our behavioral health services are available for childrens ages 0 to 21 at our Lake View Terrace location.  If you would like to refer your child or make a referral on behalf of a family, please complete this online form.  An intake specialist will then reach out via phone to gather pertinent information and schedule that child and their family for an initial intake appointment with one of our trained clinicians.  If you have questions or want more info first, please feel free to reach out to our team at (818) 686-3000 and they will be able to speak with you to discuss any questions you may have.

"*" 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*