Make a Referral

Step 1 of 5

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How can we help?

CHS Community(Required)

Where do you reside? If unsure of your official "CHS Community" see locations linked above to search your county.

Service Requested in Broward(Required)

Family Visitation

Counseling

Service Requested in Emerald Coast(Required)

Community Partnership Schools

Counseling

Early Steps

Healthy Families

Service Requested in Gainesville(Required)

Community Partnership Schools

Counseling

Service Requested in Lakeland(Required)

Child Protection Team

Children's Advocacy Center

Counseling

Healthy Families

Targeted Case Management

Service Requested in Ocala(Required)

Counseling

Healthy Families

Service Requested in Palm Beach(Required)

Adoption

Bridges

CINS/FINS

Community Partnership Schools

Counseling

Post Adoption Support

Safe Harbor Shelter

Teen Outreach Program (TOP)

Service Requested in Space Coast(Required)

Community Partnership Schools

Counseling

Early Head Start

Family Services Planning Team

Targeted Case Management

Service Requested in Tampa(Required)

Community Partnership Schools

Counseling

Service Requested in Daytona(Required)

Community Partnership School

Counseling

Family Services Planning Team

Family Transition

Family Visitation

Healthy Start

Independent and Transitional Living

Mobile Response Team

Putnam County Family Resource Center

SNAP® (Stop Now And Plan)

Service Requested in Fort Myers(Required)

Counseling

Healthy Families

Service Requested in Jacksonville(Required)

Community Partnership Schools

Counseling

Family Connects

Family Life Education

Family Services Planning Team

Healthy Families

Healthy Start

Service Requested in Miami(Required)

Community Partnership Schools

Counseling

Family Preservation and Stabilization

Healthy Families

Service Requested in Orlando(Required)

Community Partnership Schools

Counseling

Early Head Start

Healthy Families

Targeted Case Management

Family Services Planning Team

Wraparound Services

Service Requested in Pensacola(Required)

Community Partnership Schools

Adoption

Counseling

Post Adoption Support

Healthy Families

Healthy Start

M-Power

YouthWorks

Street Solutions

Family Visitation

Wraparound (WRAP)

Social Services Navigator Program

Teenspace

Service Requested in Tallahassee(Required)

Community Partnership Schools

Counseling

Family Resource Centers

Early Steps

Service Requested in Treasure Coast(Required)

Adoption

CINS/FINS

Child Protection Team

Community Partnership Schools

Counseling

DJJ Prevention

WaveCREST Shelter

For Early Steps Referrals, please visit https://flei.casetivity.com/pages/ChildReferral

For Child Protection Team referrals, please call the Florida Abuse Hotline, available 24/7, 1-800-962-2873

Type of counseling requested

In-school counseling

In-home counseling

In-office counseling

Telehealth counseling (Video sessions) (may be the only option in some areas)

All types of counseling may not be available in your community.

Please list the name of the school

Note: in-school counseling may not be available in your community

The person submitting the referral is the

Parent #1's name

First Last

Parent #2's name (if applicable)

First Last

Child's Birth Date or Due Date

MM slash DD slash YYYY

Name of Person Making Referral

First Last

Referring agency/program/doctor's office

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County of residence

Phone

Living Situation

With Parents/Guardians

With Parents/Guardians but ran away

Independent/On my own

Homeless

School Status

Enrolled and attending school

Enrolled but not attending school

Dropped out/not attending school

Homeless

Client/Family Information:

Client Name

First Last

Medicaid number, if known

Name of insurance company, if applicable

Address

Street Address Address Line 2 City State ZIP Code

Date of Birth

MM slash DD slash YYYY

Gender

Language

English

Spanish

Creole

Other

Phone

Client/Family Information:

Who has the authority to consent to treatment for minor child?

First Last

Relationship to child:

Parent

Relative

Foster Parent

Case Manager

Other

Currently taking psychotropic medications?

Yes

Unsure

Check here if this is an urgent need

This is urgent

Client has mental health or substance abuse history

Yes

Unsure

Referral reason

Currently receiving other services?

If yes, where?

Our team will reach out to you promptly.

CHS Master Referral Form

How can we help?

For Early Steps Referrals, please visit https://flei.casetivity.com/pages/ChildReferral

For Child Protection Team referrals, please call the Florida Abuse Hotline, available 24/7, 1-800-962-2873

Client/Family Information:

Client/Family Information: