Self-Referral for Care
This form helps our team understand your unique needs and ensures we provide the most appropriate support for your journey. Please note that this form is for non-emergency referrals only. If you are experiencing a crisis, please contact emergency services immediately.
IMPORTANT: EMERGENCY NOTICE
If you are experiencing a life-threatening emergency, a mental health crisis, or are in immediate danger of harming yourself or others, please stop and call 911 or go to your nearest emergency room. This form is not monitored for urgent crises.
Please complete this self-referral form as thoroughly as possible. Your information helps our clinical team understand your needs and determine how we can best support your journey toward stabilization and recovery. This initial assessment is part of our trauma-informed care process.
After You Submit
What happens after I submit the referral form?
Once submitted, our clinical intake team will review your information to ensure we are the right fit for your needs. We use this data to match you with the most appropriate provider and prepare for your initial evaluation.
How quickly will the clinic respond to my request?
We strive to respond to all self-referrals within 24 to 48 business hours. You will typically receive a phone call or a secure email from our administrative staff to discuss the next steps and scheduling.
What should I do if I am experiencing a mental health crisis?
This form is not for emergency use. If you are in immediate danger or experiencing a crisis, please call 988 (the Suicide & Crisis Lifeline), call 911, or go to the nearest emergency room immediately.
Is my information kept private and secure?
Yes. Your privacy is our highest priority. All information submitted through this form is handled in accordance with HIPAA regulations to ensure your personal health information remains confidential and secure.