CK Behavioral Health Referral Form

CK Behavioral Health Referral Form

Thank you for choosing CK Behavioral Health for your Child or Youth's behavioral health needs. Please complete this form to the best of your ability with as much information as you are able to provide. After tapping the submit button we will get to work on it and will be in touch soon.

Referral Source Information Section

Service Delivery Method

CK Behavioral Health provides services through two methods; 1) Traditional through which our staff and client are in the same room at the same time or, 2) Telehealth where our staff visit with our client via secure video calls (involving a smartphone, tablet, or computer) to provide services.

Child or Youth Information Section

Parent/Legally Authorized Representative Information Section

Please check all that apply.
Examples include (but are not limited to): emergency room visits, 23 hour observation periods, need for mobile crisis response, emergency respite, etc . . .
Please check all that apply.
Please check all that apply.

Foster or Adoption Family Home Information Section

Kinship Family Home Care Information Section

Our Community Our Kids (OCOK) Information Section

Child Protective Services Information Section

Child or Youth's Risk Screening Section

Child or Youth's Treatment History Information Section