Therapeutic Services Referral Form
Thank you for choosing Gateway Mountain Center for your mental health needs! Our staff are eager to help you discover and fully realize your best self. To help us do our best to meet your unique needs please fill out the form as completely as possible.
Email address *
Gateway has an AWESOME array of youth programming & services. Let's start by exploring some possibilities from our most popular and sought after options. (pssst it's okay if you are unsure. We'll help you out!) *
Required
Client Information
Let's get into some of the nitty-gritty details that will help us jump start the process of serving you the best we can.
Client Name *
Birth Date *
MM
/
DD
/
YYYY
Age *
Gender *
Family Information
Primary Parent / Guardian if services are for a minor
Name
Phone Number
Email
Home Address
Ability to Pay
Gateway seeks family support to pay for programs whenever possible. Gateway is also often able to serve families who can not pay for services. Please share what your current ability to pay is for the services provided.
Ability to Pay *
Referring Party Contact Information
If different from parent/guardian
Agency/Organization (if applicable)
Name
Phone
Email
Relationship to Client
Clear selection
Are you available to talk about this referral?
Clear selection
Reason for Referral
Please briefly describe the reason(s) for the referral. What are the specific needs? *
What would be the desired outcomes upon completion of services? *
Submit
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