EHP Location *

Select location

Referring Provider Information: (If applicable)

Referring Agency *

First Name *

Last Name *

Phone *

Email *

Individual's Name

Your First Name *

Your Last Name *

Guardian (If Applicable)

Date of birth *

Your Phone Number *

Street Address

City

State

Country

Postal code

Insurance Carrier

Insurance ID Number

Group #

Current Services Received (if any)

Services Offered / Requested

Tranquility Grove

Tranquility Grove (ASAM 3.1 Substance Use Residential Treatment)

All Site Locations

Mobile Crisis (dispatched by 988 ONLY)

Outpatient Community Stabilization(all ages with referral from higher level of care)

Mental Health Skill Building (adults)

Outpatient Therapy (children, teens, adults, family)

Tele-psychiatry

Danville Office Only

Intensive In-Home Services (children/adolescents)

Substance Use Intensive Outpatient (SUIOP, 18 years or older with current substance use)

Substance Use Partial Hospitalization (SUPHP, 18 years or older with current severe substance use)

Mental Health Partial Hospitalization (MHPHP, 18 years or older with significant mental health issues)(25 hours/week)

Mental Health Intensive Outpatient (MHIOP, 18 years or older with significant mental health issues)(9hours/week)

Please Check Behaviors Of Concern And/or Describe The Specific Details For The Referral Below

Talking Back/disrespect

Truancy/school Avoidance

Poor Social Skills

Disruptive Behavior

Inattention/hyperactivity

Self-Harm

Not Listening

Bullying (Victim Or Perpetrator)

Making Threats

Tantrumming

Nervousness/Anxiety

Academic Issues

Hitting/Throwing/Kicking

Sadness/Depression

Trauma

Anger Issues

Low Self-esteem

Involvement With Law Enforcement

Isolation

Excessive Crying

Adjustment Issues

Observed Behaviors

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