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Niagara County Referral
Please fax all information to 716.322.6501 or email admin@cphbuffalo.com
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Email *
Were you referred to CPH Mental Health Counseling through Niagara County? If no, please exit out of this form and fill out our intake appointment request form.  *
Who are you referring to CPH Mental Health Counseling?  *
What is your affiliation to the child?  *
What is your name and contact information?  *
What is the child's biological parents name and contact information?  *
What is the child's foster parents name and contact information?  *
What is the child's full name and date of birth?  *
Are siblings apart of this case? If so, please list all siblings involved and their contact information.    *
Do you have a case ID number? If so, please provide.  *
What services are you seeking for the family?  *
Required
Who should we send reports to? (please provide name, full address, email, and /or fax number)  *
Who has custody over the child? (please provide full name and contact information)  *
What service providers are involved with the family? Please provide full names and contact information.  *
When is the next court date?  *
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What records have you provided to us?  *
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Is there any other information you would like to provide to us?  *
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