College Now - Outpatient Behavioral Health Referral

Date: Click or tap to enter a date.

Name: Click or tap here to enter text.
Address: Click or tap here to enter text.	Date of Birth: Click or tap to enter a date.
Phone Number: Click or tap here to enter text.	Email: Click or tap here to enter text.
Insurance Type: Choose an item.

Name & Title of Person Initiating Referral: Click or tap here to enter text.
Phone: Click or tap here to enter text.	Email: Click or tap here to enter text.
Is the person being referred a College Now recipient? Choose an item.
Was the person notified of the referral? Click or tap here to enter text.

Check all related mental health concerns:

☐ Anger Management (arguing, irritability, fighting, yelling, etc.)

☐ Trauma/PTSD (abuse, domestic violence, witnessed trauma, etc.)

☐ Depressed Mood (overall sadness, low/restricted activity levels, crying, poor appetite)

☐ Anxiety (acting in a fearful manner, appears overly stressed, inability to cope with daily functioning, panic)

☐ Adjustment (recent changes or stressors impacting functioning)

☐ Other: Click or tap here to enter text.

Please describe the reason for completing this referral: Click or tap here to enter text.