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.

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Person Completing This Form
How did you hear about the Village?
Please select the source.

Above, please include ...
NAME OF ENTITY (county, hospital, private practice, treatment system, search engine, etc.) ... and
YOUR CONTACT THERE (name, phone number, and email address), if applicable.

How did you hear about the Village?

Through a Child Public Agency / Judicial System?


Through a Hospital / Private Practice / Treatment System?


Through a Search Engine / Other?

Child's Information
Child's Legal Guardian
Are you the legal guardian?
Does the child reside with you?

Contact information for legal guardian, if someone other than you ...

Insurance Information

Primary Insurance


Secondary Insurance

Child's School Information
Type of School

If Public / Private / Alternative school ...

Does the child have an IEP or 504 plan?
Child's Current and Past Treatment Services

PLEASE INCLUDE:
Treatment provider's name, phone number, and email address.
Services provided, service start date, and how many times per week.

Child's Legal Involvement

Does the child have any current legal involvement with the judicial system?

Please include Court Hearing Date, Charge, and Explanation.

Is the child currently in a detention center?


Is the child currently in state custody?


Is the child currently facing state custody?

Child's Behavior History
Level of Aggression
Target(s) of Aggression
Child's Health History

If the child is diabetic ...

Is the child currently on medication for diabetes?
Is the diabetes controlled by the medication?

Substance Abuse
Documents / Records

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.

Combined total of all files may not exceed 7MB.

Max File Size: 7MB

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.

Ready to take the next step?
An assessment is an important first step toward treatment of and recovery from addiction.