Request Comprehensive Community Services (CCS)

We're so happy that you have found us. Our clinicians are currently full and working from a waiting list. Please fill out the form below to be added to our waiting list. We will contact you when a clinician becomes available. We are continuing to hire high quality clinicians to meet the needs of our community.

If you are requesting outpatient services, please use the Outpatient Mental Health Counseling form.

Refer a Consumer

Referring Agency Name

Referrer Name

First Name

Last Name

Referrer Phone

(###)

###

####

Referrer Fax

(###)

###

####

Referrer Email

Services Being Requested

Check all that apply. Include details in the "Other Information" section below.

ISDE

Psychoeducation

Psychotherapy

Wellness & Recovery

What days of the week and times of day is the consumer available?

Consumer Information

Name

First Name

Last Name

Date of Birth

YYYY

Age in Years

Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

School District

Include if consumer is under 18.

Guardian Information

Guardian/Parent Name

Guardian Relationship

Guardian Contact Information

Presenting Issues and Symptoms

Current Diagnosis

Please share current diagnosis and/or medications including the name of prescribing doctor.

Goals

Please share goals to be accomplished through services.

Other Information

Please share strengths as well as any other relevant information, including any current services.

Request Comprehensive Community Services (CCS)

If you are requesting outpatient services, please use the Outpatient Mental Health Counseling form.

Our Locations

Contact Information