* Required Field
REFERRER INFORMATION:
Your Name:
Referring Organization/Facility:
Your Email:
Your Phone:
 
CLIENT/PATIENT CONTACT INFORMATION:
First Name:*
Last Name:*
Gender:*
Race:*
E-mail Address:
Phone Number:*
 
okay to text
Street Address:
City:
County:*
State & ZIP Code:*
Insurance:*
Member ID or Medicaid MMIS#:
Date of Birth:
Needs Interpreter:
If referring from a hospital or outpatient office, please provide contact information for your facility's interpreting service

BRIEF REASON FOR REFERRAL:
Services requested (please check all at apply)
Counseling
Psychiatry
Legal Assistance
Case management
Family Advocate
Not listed (please describe below)
Verification Word:  To help us reduce fraudulent submissions, please type the word shown below into the box provided:

(lowercase or uppercase)

If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org


By clicking the "Submit Referral Form >" button below, I understand that the information I submit will be used by MHA OHIO to match me with the most appropriate service(s) based on my problem or other factors. Certain information may be provided to these programs so that they have basic information about my situation.


Please click the button only ONCE. It will take a few moments for the submission to complete.