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Youth Referral Form:
Referral Page
Person Completing Form
*
Referring Party Phone Number
*
Email
*
Child’s Name
Date of Birth
Parent/ Guardian’s Name
Parent/ Guardian Phone Number:
Date Parent/ Guardian Consented to Referral
Address
Select the service you are interesting in receiving services for:
*
Individual Therapy
Family Therapy
Youth Case Management
Other
Other
Reason For Referral
Insurance
Medicaid
Medicare
BCBS
Aetna
United
Allegiance
Pacific Source
Mountain Health Co-Op
Private Pay
Other
Other
Preferred Clinician
Cody Bryant
Maureen Bryant
Susan MacLean
Ruth Guthrie
Ruby Zitzer
Ryn Briggs
Lora Trevis
Ike Wallace (Case Management)
No Preference
Other
Preferred Clinician
Submit
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