Village Behavioral Health Child Referral

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Child's Information:




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Insurance Information:



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Legal Guardian Contact Information:


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School Information:

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Background Information:


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Past Treatment Providers




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Legal Involvement




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Petitions:


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Behavior - Past Year History
















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Mental Health





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Substance Abuse - Past Year History



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Please free to use this section to upload recent documents and/or records that may help in the admissions process. For example; recent discharge paperwork or psychological evaluation.