Referral Form

Instructions to complete the referral form:


Please complete all blanks with as much information that is available.

If this is a psychiatic emergency, please call our office from the numbers on the website or our crisis line at 1-800-239-4673.

If a child is under age 14, we must have permission from a parent or legal guardian to see the child. 

Once the form is completed, you may fax it to our offices.

328 W. Claiborne St.
P.O. Box 964
Alabama 36460
Tel: (251)575-4203

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