Referral Form

THIS INFORMATION IS SENT ENCRYPTED AND IS SECURE.

After we receive your information it will be reviewed and sent to the appropriate department.
Items with * are required.

This referral form is for professionals and individuals who are referring someone for mental health services at CSI. This includes schools, healthcare providers, colleges, employers, DCF, social workers, and family members. If you're unsure whether you should use this form, please contact our office and we’ll guide you through the next steps.

Part 1 Your information

Your information as the referral source is important, should we need to contact you for additional information.

Part 2 Person being referred

If you are referring yourself add your information. If your child add your child’s info.

What is the sum of 6 and 9?