Fill in the form below to complete the referral: Please enable JavaScript in your browser to complete this form.Your Name (Referring Person) *FirstLastPhone Number (Referring Person) *Email (Referring Person) *What organization/agency are you from? *Name of who you are referring *FirstLastPut child's name if that will be the clientClient/Parent Email *Adult name if client is a minorFirstLastBest way to get a hold of client/family *Phone number(s), email, school they attend etc. What are you referring them for? *Individual CounselingFamily CounselingNeurofeedbackCase ManagementMed management (Coming Soon!)IHBTMedicaid Billing Number or SSN *Client Date of Birth *Release of Information Click or drag a file to this area to upload. Other information we should know to get started with the individual/family:Submit