Behavioral Health Referral Form
Welcome to the GCC Behavioral Health Referral Form. This form is designed to streamline the process of referring individuals or yourself for specialized behavioral health support. Your referral will help connect individuals and/or yourself with the appropriate care and support that they or you may need.

What is Behavioral Health?
Behavioral health refers to the field that addresses the connection between behaviors, mental health, and overall well-being. It encompasses a broad range of conditions and interventions that impact how individuals think, feel, and act, and how these factors influence their overall health. It is about understanding and managing the behaviors and mental health conditions that influence overall health and quality of life. It involves a multidisciplinary approach to provide comprehensive care and support.

What is CYBHI?
CYBHI is the Child and Youth Behavioral Health Initiative. It is a program meant to address the connection between behaviors, mental health, and overall well-being. It encompasses a broad range of conditions and interventions that impact how individuals think, feel, and act, and how these factors influence their overall health. It involves a multidisciplinary approach to provide comprehensive care and support.

Confidentiality Notice:
All information submitted through this form is confidential and will be used solely for the purpose of facilitating the referral process and ensuring the individual receives appropriate care.

PLEASE NOTE: 
The client and/or family will be contacted within 72 hours of the submission of the referral. 

If you have any questions or need assistance with this form, please contact Rita Ozeruga at rita.ozeruga@gcccharters.org.

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Email *
Referring Person's Information
If you are referring yourself, please move on to the next section.
Referring Person's Full Name
Referring Person's Title
Referral Date
MM
/
DD
/
YYYY
Phone Number
Relationship to the Individual Being Referred
Is the individual aware that they are being referred?
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