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Referral Form

Admission Criteria

To be eligible for our program, individuals must meet the following criteria:


Age Requirements

Open to children, adolescents, and adults, with a minimum age requirement of 5 years for admission.



Must have a DSM-IV-TR, Axis I diagnosis that includes schizophrenia, bipolar disorder, major depression, or falls within the severe and persistent mental illness category. This program also accepts individuals with co-occurring substance abuse/dependence diagnoses.


Hospitalization Risk

Identified as at risk for psychiatric hospitalization. This generally includes those who have been admitted to a psychiatric hospital three or more times within a 3-month period.


Additional Health Factors

Must have psychosocial and/or medical factors that contribute to their inability to stabilize effectively within the community.


Support Needs

Requires structured and community-based support to achieve stabilization within the community.

Complete the confidential form by clicking the button below then hit the SUBMIT to send your form.

Sections include:

  1. Demographics

  2. Referral Source (if not applicable, please check the box)

  3. Guardian Information (if not applicable, please check the box)

  4. Insurance Information

  5. Referral reason (a summary of the symptoms)

  6. Submit page -  To submit, all required fields must be completed.

We will follow up with you shortly after.  If you have any questions, please call use at 713-686-9194 and ask about Intake at your preferred office.

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