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SPARC Services & Programs Referral Form

Referral Demographics

Referral Name(Required)
MM slash DD slash YYYY
Gender(Required)

Insurance Information

More Demographics

Guardian Information (If Under 18)

Guardian Name

Referrer Information

Referred by(Required)

Clinical Information

Has the client been seen for services in the last 90 days?(Required)
Emergent: A life-threatening condition (possibly due to substance use) in which client might hurt self or others, and/or is unable to care for self.

Urgent: Client is not currently at risk of hurting self or others, but experiencing feelings of hopelessness, helplessness or rage; have a condition that could rapidly worsen without immediate help, or due to substance use the client is in need of prompt help to avoid making their condition worse.

Routine: Client shows signs and symptoms that are interfering with their quality of life, or show signs and symptoms caused by substance use, resulting in a level of impairment that interferes with quality of life.

The SPARC Network can only receive complete referrals. A complete referral includes your information and the contact information for the parent or legal guardian (if applicable). Also, if the client is currently receiving MH services, please attach the most current CCA and PCP. Attachments must be in PDF format.

Drop files here or
Accepted file types: pdf, Max. file size: 300 MB.