inside of classroom. Floor has eight squares taped on the ground. Many cubbies and cabinets along the back wall. Table with small chairs for children along the front wall.

Mental Health Referral

Referral for FSGC Services

Information for referrals

This form is intended for doctors/pediatricians, mental health professionals (including private practitioners in the community), school staff and daycare/childcare providers.

Complete the information below. Be sure to click “Submit” to send your form to us. FSGC Admissions will contact the individual, parent/legal guardian or family member to set up an appointment. (NOTE: An asterisk * indicates required information.)

NOTE: Family Service & Guidance Center will only contact the family if our providers have discussed services prior to the submission of this form.

Referrer & Client Information

"*" indicates required fields

MM slash DD slash YYYY
Has the referral been discussed with the family?*
This field is for validation purposes and should be left unchanged.