MAKE A REFErRAL

Know someone who would benefit from our services? Complete our CSEUC Referral Form and an Authorization to Release Information Form, and then fax it to one of our locations near you. 

Downloadable Content:  Authorization to Release Information Form / CSEUC Referral Form

 

ONLINE rEFERRAL fORm

Unsure if CSEUC is the right option? Complete our quick online referral form and a staff member will be in touch to provide/request further information. 

Consumer's Age *
Our services can only be provided to individuals age 4 and older*
Consumer's Gender
Not required
Consumer's Marital Status
Not required
Name of Person Making the Referral *
Name of Person Making the Referral
Referral Source's Primary Phone # *
Referral Source's Primary Phone #
Referral Source's Primary Fax # *
Referral Source's Primary Fax #
How Would You Like to be Contacted?
Please select all that apply*
Reason for Referral *
Please select all that apply*
Services Being Requested *
Please refer to our Overview of Services tab for admission criteria and description of each service* Please select all that apply*