Referral – Connections365

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- Behavioral Rehabilitation Services
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Home
Mental Health Services
Referral
Programs
- Behavioral Rehabilitation Services
About Us
Careers
Contact

Refer a Youth for Support

Submit a referral to connect a youth with the appropriate mental health, behavioral, or residential support. Our team will carefully review the information and follow up within 1–2 business days to ensure timely next steps.

Youth Information

Your Name

Date of Birth

Age

Gender

Current Living Situation

County of Residence

Referral Source

Full Name

Organization / Agency

Role / Title

Phone Number

Email Address

Reason for Referral

Primary Needs (Select all that apply)

Mental Health Services Behavioral Support Residential Placement (P180 / Continuum) Transition / Step-Down Support Family Support Services

Brief Description

Clinical & Behavioral

Current Diagnoses (if known)

Medications (if applicable)

History of

Trauma Behavioral incidents Prior placements or services

Optional details

Risk & Safety

Any current safety concerns?

Yes No

If yes, please describe

History of (check all)

Self-harm Aggression Substance use

Insurance

Insurance Provider (if applicable)

Medicaid / OHP Status

Referring Agency Funding (if applicable)

Additional Info

Upload Documents

Additional Notes

Consent & Submit

Is this referral urgent? (optional filter)

Immediate (24–48 hrs) Standard

Preferred appointment type (optional)

In-person Telehealth

I confirm that the information provided is accurate to the best of my knowledge I have appropriate authorization to submit this referral

Prefer to Speak with Someone?

503 588 5647
Jennafer.Toone@connections365.org

Urgent? Call our intake directly

Supporting youth through compassionate care, mental health services, and behavioral rehabilitation.

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Contact Info

503 588 5647
Jennafer.Toone@connections365.org

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Thank You — Referral Received

Our intake team has received your referral and will review it shortly. You can expect a response within 1–2 business days.

If this is urgent, please contact us directly.

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