New Member Referral

For use by licensed mental health professionals

Dear mental health professional:

Thank you for your interest in referring a prospective member to the Academy. We are pleased to offer an encrypted, secure electronic submission option. Please complete the online form below. Items marked with an (*) are required.

Alternatively, you can download the PDF, print our new member referral form and return it to us by regular mail, confidential fax, or drop it off at one of our locations.

For assistance, contact our Enrollment Coordinator.

Note: If you are an applicant and would like to apply for membership for yourself, please visit: new member application.

Progress:

Referral Form

Step 1 of 3: Prospective member information

* Name

* Date of birth

* Street address

Apartment/unit #

* City

* State

* Zip

* Phone

Social Security #

* Reason for referral/goals

Progress:

33%

Referral Form

Step 2 of 3: Diagnosis

* Primary diagnosis

Secondary diagnosis

Tertiary diagnosis

GAF (if known)

* Traumatic Brain Injury

* Autism Spectrum Disorder

* Developmental or Intellectual Disability

Risk assessment

Violence

* Past history

* Current activity level

Suicide attempt(s)

* Past history

* Current activity level

Alcohol/drug abuse

* Past history

* Current activity level

Sexual exploitation

* Past history

* Current activity level

Additional information

Describe any known legal involvement

Additional risk assessment comments

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New Member Referral

Progress:

Referral Form

Step 1 of 3: Prospective member information

Progress:

Referral Form

Step 2 of 3: Diagnosis

Risk assessment

Violence

Suicide attempt(s)

Alcohol/drug abuse

Sexual exploitation

Additional information

Progress:

Referral Form

Step 3 of 3: Licenced clinician information

Stop by and see what we're all about

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