Gateway Clinical Service Referral
Thank you for choosing Gateway Mountain Center for your mental health needs! Our staff are eager to help you discover and fully realize your best self. To help us do our best to meet your unique needs please fill out the form  as completely as possible.
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電子郵件 *
Information About the Person Being Referred for our Services
Legal Name of Person Being Referred *
Preferred Name of Person Being Referred
* Please leave blank if it is the same as the legal name
Birth Date *
MM
/
DD
/
YYYY
Age *
Gender Assigned at Birth *
In their own words, what is their gender identity?
* Please leave blank if it is the same as the previous answer
Family Information
Primary Parent / Guardian if services are for a minor
Name
Phone Number
Email
Home Address
Ability to Pay
Gateway seeks family support to pay for programs whenever possible. Gateway is also often able to serve families who can not pay for services. Please share what your current ability to pay is for the services provided.
Insurance *
Referring Party Contact Information
If different from parent/guardian
Agency/Organization (if applicable)
Name
Phone
Email
Relationship to Client
清除選取的項目
Are you available to talk about this referral?
清除選取的項目
Please briefly describe the reason(s) for the referral. What are the specific needs? *
What would be the desired outcomes upon completion of services with a Gateway Clinician? *
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