Referral/Request

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Reason For Referral(Required)

Date of Birth(Required)

Client Phone(Required)

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Parent/Guardian Information

Only needed for clients age 15 and younger

Parent/Guardian Phone

Parent/Guardian Email

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Consent to Release

* I consent to have my clinic share the information on this form with Wilder’s Mental Health Services and that they will contact the identified caregiver.
* I consent to have Wilder provide feedback to my clinic about the status of this referral for mental health.
* I understand I may refuse to sign (and can revoke) this referral and consent, except to the extent that action has already been taken in reliance on this consent.
* I understand that my clinic may not condition treatment/services or payment of bills on decision to sign this referral and consent form.
* I understand that when the information specified on this form is sent to Wilder's Mental Health Services, they have agreed not to re re-disclose the information to any third party other than this clinic and to protect the privacy of this information consistent with state and federal privacy laws.
* I agree that a photocopy of this form is as valid as the original.
* I understand that, upon my request, I will receive a copy of this signed form.
* I have read and agree to the terms above above.

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Client/Parent/Guardian Signature

NOTE: Please let the client and parent(s)/guardian(s) know that you have made this referral and that we will be contacting them to schedule an appointment. Most clients begin by having a diagnostic assessment appointment with one of our mental health clinicians in order to assess the client’s current mental health and service needs and discuss any concerns with parents/guardians. As always, we appreciate the opportunity to work with you and look forward to our collaboration.

Today's Date(Required)

In a few sentences, please explain any questions you have or services you are seeking(Required)

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Email Address(Required)

Phone Number(Required)

How did you hear about us?

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Upload Copy of Your Voucher*(Required)

Max. file size: 50 MB.

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In a few sentences, please explain any questions you have or services you are seeking(Required)

Do you need an interpreter or translation services?(Required)

Language Description

How would you like to be contacted?(Required)

Is it ok if we leave a detailed message on your phone?(Required)

How did you hear about us?

Phone

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Child's Date of Birth*

Which of the following best describes your child?*

What is your preferred method of payment?*

What time works best for you to take a tour?*

How did you hear about us?*

Another Wilder program or service*

Have you contacted our Child Development Center before?*

Specify if you have called, emailed or visited us before*

Comments

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I would like to know more about aging and caregiving services for...(Required)

Select any of the services you would like to know more about(Required)

Can we leave you a detailed message?(Required)

How did you hear about us?(Required)

Referral/Request

Community Mental Health & Wellness

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Parent/Guardian Information

Health Insurance

Consent to Release

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