Start a referral for a child in crisis

Use this form to begin a referral. Share the referring professional's contact details and non-clinical basics — our team will follow up quickly and provide a secure method for clinical documents.

This form is not for emergencies

If a child is in immediate danger, call 911. For a mental health crisis, call or text 988 or your local crisis line. This form is not continuously monitored.

Protect health information: Please share only what's requested below. Do not upload clinical records, medication details, or other protected health information here. Once we receive your referral, our team will provide a secure, HIPAA-compliant method to exchange clinical documents.

Don't fill this out:

Referral source

Your name *

Agency / organization

Phone *

Email *

Youth information (non-identifying)

Youth initials *

Age *

Gender

Current location

Legal guardian / custody contact

Presenting crisis

Briefly describe the presenting concern

Insurance / funding source

Timing

Urgency *

Requested admission date

Attestation I confirm the information above contains no protected health information beyond what is requested, and I understand a team member will contact me to securely exchange clinical documents. *

Referral received

Thank you. A member of our admissions team will review your referral and follow up promptly — including a secure way to share clinical documents.

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