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Children's Services External Provider Referral

Complete the following form in order to submit a referral for services. 

Please be advised that services listed with an asterisk have eligibility requirements. 

Reach out for more information.

What type of referral would you like to make?
Have the child been hospitalized in the last 30 days?
Does the child receive additional external services?
DHS/CUA Involvement?
Special Education placement?
Does the child have an IEP?
Is the parent aware of this referral is being submitted if child is under the age of 13 years old or is the child aware that this referral is being submitted if the child is14+ years old?
Is there a custody agreement?
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