Adult BH Services Referral Form
Please fill out as much information as you can when making a referral, this will help WAPI Community Service Staff to serve the youth. Thank you!
WAPI Community Services 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.
Type of Service(s)
Alcohol and Drug Assessment
Substance Use Disorder (SUD) Screening and Treatment Services
Mental Health (MH) Screening and Support Services
Reason for Referral (check all apply)
Parent/Family/Friend concerns of emotional health and/or substance use behaviors
Service Provider concerns of emotional health and/or substance use behaviors
Self-Referred/Individual concerns about their emotional health and/or substance use behaviors
Employment/Legal Requirements (ie. DUI, probation, etc.)
Please provide a brief description of presenting concerns
Is the individual REQUIRED to follow through if treatment is recommended?
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This form was created inside of WAPI Community Services.