Refer a Client

Referral Form

Thank you for partnering with Peter Project.

Please complete the referral form below for any child, youth, or family who may benefit from behavioral health support, mentoring, skills training, case management, or community-based and therapy services.

To help us process the referral quickly, please provide as much information as possible. If a section does not apply or you do not have the information available, please enter N/A.

Once the referral is submitted, our team will review the information and follow up regarding eligibility, next steps, and service availability.

We appreciate your partnership in helping connect families to supportive, faith-based behavioral and mental health services.

Referral Source

Name of the Person making Referral

Relationship to Client

Phone Number

Agency/Institution Name (if any)

Choose state

Referral Information

Date Of Referral

Time Of Referral

Nature Of Referral
RoutineUrgentEmergent

Care Was Provided
yesno

Offered But Declined Appointment
yesno

Access Was Available But Not Seen
yesno

Scheduled Within 7 Days But Did Not Show
yesno

Client Person Information

Client Name

Client Date Of Birth

Client Unique Id/Record #

Does Client Have Insurance?
yesno

Insurance Name

Policy Number

Does Client Have A Guardian
yesno

Client Contact Information

Client Address

Client Phone Number

City

State

Zipcode

Guardian/Next To kin

Guardian/Next To Kin Phone Number

Guardian Email

Presenting Problem or Need

Tick All That Apply
Mental HealthBehavioral ConcernsDepressionAnxietyTraumaAggressionSubstance UseIntellectual / DevelopmentalSchool ConcernsFamily ConflictSelf-HarmOther

Reason for Referral/Current Problem Or Need

Pertinent Past Information / Relevant History:

Proposed Service Delivery to Meet Problem or Need

Proposed Service To Meet The Problem Or Need
Psychosocial AssessmentIndividual TherapyMedication ManagementSkills Training & DevelopmentTargeted Case ManagementOther

Other Relevant Information

Include other information discussed during referral that could assist care planning:

Emergency Contact

Name

Number

Relationship

For Internal Use

Staff Scheduler

Client Contact Date

Assigned Staff

Notes