Make a Referral Online

If you have a referral you may either call us directly or complete the form below and submit to us. All information is completely confidential.

Use of this referral form is the first step in the process for Village Behavioral Health to consider your child for residential treatment services. Submission of this form will be followed by a phone call.

Thank you.

Notice of Privacy Practices click here.  
 

Village Behavioral Health Child Referral

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Child's Information:




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Insurance Information:



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Legal Guardian Contact Information:


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School Information:

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Background Information:


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Past Treatment Providers




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Legal Involvement




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Petitions:


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Behavior - Past Year History
















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Mental Health





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Substance Abuse - Past Year History



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Please free to use this section to upload recent documents and/or records that may help in the admissions process. For example; recent discharge paperwork or psychological evaluation.

Need assistance with this form?