EHP Location *

Referring Provider Information: (If applicable)

Referring Agency *

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Individual's Name

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Street Address

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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)

Observed Behaviors

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