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Programs & Services
Overview
Adult Programs
Acute Psychiatric Care
Dual Diagnosis
Partial Hospitalization (PHP)
Intensive Outpatient (IOP)
Child & Adolescent Programs
Acute Psychiatric Care
Sub-Acute Adolescent Program
Adolescent Male Extended Care Unit
Substance Abuse
Telehealth
Services for Veterans, Military, and Dependents
About Us
Overview
Our Facility
Our Team
Licensing & Accreditation
Partnerships
Admissions
Referrals
Resources & Events
Visiting Hours
What to Bring
Continuum of Care
Events for Professionals
Therapeutic Thursdays
Video Library
Referral Form
UHSAdmin
2026-06-18T10:06:03-04:00
Referral Form with File Upload
Phone
This field is for validation purposes and should be left unchanged.
Treatment Program Interested in
Children & Adolescent Programs
Acute Psychiatric Inpatient Program (Male and Females ages 4-17)
Adolescent Male Extended Care Unit (Males 12-17)
Adolescent Sub-Acute Program (Male & Female 12-17)
Adult Inpatient Programs
Adult Acute Psychiatric Inpatient Program
Adult Inpatient Dual-Diagnosis/Co-Occurring Mental Health & Substance Use Treatment program
Adult Outpatient Programs
Adult Partial Hospitalization Program (PHP) M-F 9:00 AM-2:30 PM
Adult Intensive Outpatient Program (IOP) M-Sat. 9:00 AM-12 PM
Adult Intensive Outpatient Program (IOP Nights) M-F 6:00PM-9:00P PM (Program opening soon)
Interested in Virtual (if approved by insurance)
Demographics
Patient Name
First
Middle
Last
Height
Weight
Birthdate
Age
Birth Sex
Preferred Name
Preferred Pronouns
Patient Cell Phone (Guardian Cell Phone, if minor)
Patient Email (Guardian Email, if minor)
Patient SSN
Insurance
Insurance Policy Number
Guardian's Name
First
Last
Relationship to Patient
Cell Phone
Home Phone
Work Phone
Is user a professional?
I am a professional referral source filling this form on behalf of a patient
Referral Source/Physician/Therapist
Referring Provider's Name
First
Last
Agency/Clinic/Practice Name
Agency/Clinic/Practice Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Cell Phone
Office Phone
Fax
Email
How did you learn about us?
How did you learn about us?
Current Therapist/Outpatient Provider
Physician/Nurse/Therapist
School
Hospital
Social Media
Website/Google
Family/Friend
Other
Provider Name
Agency/Clinic/Practice Name
School Name
Hospital Name
Staff Member Name
Which social media?
Facebook,
Instagram,
LinkedIn
How did you learn about us?
Reason For Referral
Check all that apply
Depression
Anxiety
Mood Changes
Behavioral Concerns
Substance Use
Suicidal Thoughts/Safety Concerns
Trauma/PTSD
Psychosis/Hallucinations (Believing things that aren't true/seeing or hearing things others can't see or hear)
Eating disorder concerns
School Academic Concerns
Family/Relationship Concerns
Other
Please provide additional details regarding current concerns/symptoms
How would you prefer to complete the level of care assessment?
In Person
Virtual (telehealth) visit
Phone
No Preference
Best contact phone number, if different than above
Additional Information
Notes
Supporting Documents
Upload any supporting documents that may assist with the referral/assessment process such as: Medication list, Insurance Card, Recent discharge Paperwork, School documents/IEP, Current Treatment Records, Psychological testing/evaluation, Therapy or psychiatric records, Letter of Recommendation-If for Sub-Acute program
Drop files here or
Select files
Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 25 MB, Max. files: 15.
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