Referral Application

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Referring Agency
Child/Adolescent
Parent/Guardian Contact Information
Custody
Is this child in custody of DSS?
Have parental rights been terminated
Reimbursement
IEP
Document Upload

PLEASE UPLOAD as many of the following documents as possible:

  • Most recent psychological evaluation and psychiatric evaluation.
  • Discharge summaries from previous treatment providers within last year.
  • Social history – Pre/Post Dispositional Report - Foster Care Service Plans.
  • Documents with Information describing behavior within past 2 months (treatment plans, nursing/progress notes, progress summary reports) indicating medical necessity for secure RTC treatment.

Combined total of all files may not exceed 7MB.