Referral

Client Referral Form

Submit a referral — our intake team responds within 24 business hours

Referring Provider / Self-Referral

Start the Intake Process

All information is kept strictly confidential per HIPAA. Fields marked * are required.

Section 1: Client Information

First Name *

Last Name *

Date of Birth *

Street Address

City

Zip Code

Phone Number *

Best Time to Call

Gender Identity

Medicaid ID # (if known)

Insurance Carrier

Member ID

Section 2: Referring Provider (or Self-Referral)

Provider / Agency Name

Contact Person

Phone Number

Email Address

Fax Number

Section 3: Service Request & Clinical Information

Select all services being requested:

Diagnostic Assessment (Mental Health Evaluation) Individual Therapy Community Support Services (CPST) In-Home Family Services (TBS) Mental Health Day Treatment Family Counseling

Presenting Concerns / Reason for Referral *

Current Safety Concern?

Safety Plan in Place?

Preferred Start Date

Additional Notes

By submitting this form, I acknowledge that the information provided is accurate and consent to its use for intake and scheduling purposes in accordance with HIPAA regulations and our Privacy Policy.

✅ Thank you! Your referral has been submitted to info@flochelleswc.com. Our intake team will contact you within 24 business hours.