Youth Behavioral Health Outpatient Program Referral Form
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WAPI Community Services Youth Behavioral Health Outpatient Program Referral Form
This referral form is for the sole use of the intended recipient(s). The information in this referral form, including attachments, may be confidential and/or legally privileged and may contain protected health information. If you believe that it has been sent to you in error, please notify WAPI Community Services (WAPI) at
and delete the message and all its attachments. Any disclosure, copying, distribution or use of this information by someone other than the intended recipient is strictly prohibited.
Service(s) Requesting (Check all apply)
Substance Use Disorder (SUD) Screening, Assessment, Support, and Treatment Services
Mental Health (MH) Screening, Assessment, Support, and Treatment Services
SBIRT (Glacier Middle School)
Reason for Referral (check all apply)
School staff concerns of emotional health and/or substance use behaviors
Parental concerns of emotional health and/orsubstance use behaviors
Service Provider concerns of emotional health and/or substance use behaviors
Legal Requirements (ie. DUI, probation, etc.)
Please provide a brief description of presenting concern
Is the youth REQUIRED to follow through if treatment is recommended?
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This form was created inside of WAPI Community Services.