Referral Form

If the Referral Criteria is met, please have the client request their current therapist, psychiatrist, doctor, or licensed clinical social worker complete an Awaken Referral Form.

COMPLETED REFERRAL MUST INCLUDE:
Eligibility Checklist
Awaken Mental Health Referral Form
Psychiatric Evaluation/Psychological Summary less than 6 months old that includes eligible primary diagnosis
Medication List
Physical (if provider has this on file)

We are offering two ways to complete the referral form.

1. Click here to fill out the referral form online.
OR
2. Download a PDF of the form and send the completed form with attachments to Dave Frey, Program Director at dfrey@awakenmentalhealth.org.