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Behavioral Health Pathway Referral

If you would like a behavioral-health provider to contact you, please complete the form below. If you would like both Mental-Health Therapy and Medication Management, please complete a separate referral for each service.

If the person being referred is under the age of 18, an electronic consent form from the parent or caregiver needs to be provided for the referral to be accepted.
Click the green "Download Consent Form" button.
Print the form, complete and sign it.
Scan the form, and save it to your computer.
Use the Browse button in STEP 3 of the Referral to upload the completed Consent Form.
Download the Consent Form
STEP 1

What type of service are you looking for?

Mental-Health Therapy is a process whereby psychological problems are treated through communication and relationship factors between an individual and a trained mental-health professional.
Medication Management for mental health is the prescription, administration, and review of medications and their side effects for the treatment of mental illness.

Select primary payment option.

Next
STEP 2

Select a Provider.

Next Back to Step 1
STEP 3



Date: 4/26/2024
Complete this section if the referral is for someone else:
If applicable, please add parent's contact information in the attached consent form


















If your primary payment is private insurance, please provide the name of the HMO or Company.

The behavioral health provider will contact you to discuss your referral concerns.


For example, you can list things like: looking for someone who specializes in gender identity, racial identity, LGBTQ+, etc.
Back to Step 2
Referral Sent

Thank you for submitting a request for referral.

We have sent a confirmation email to the address provided in the form.

The provider you selected should follow up with you within two business days.

Start a New Form