Make a Referral Online

We work hard to build strong relationships with professionals, creating a seamless referral system so that patients receive the absolute best care possible.

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.

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.

An Ideal Place to Heal

With a serene environment, individualized treatment plans, engaging activities, and top-of-the-line education for each adolescent, Village Behavioral Health sets itself apart as a treatment center that makes positive change in each child’s life.

Most Insurance Accepted. Call for Free Verification.
  • Aetna
  • Beacon Health Options
  • Blue Cross Blue Shield
  • Cigna
  • United Healthcare
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