Phoenix Care Systems Admissions

	Referral Application To make an informal referral or information request, please complete the form below and click "submit", or you can contact an Admission Professional directly by calling 866-225-4459, ext. 1080. All information we receive is handled in accordance with HIPAA (Health Insurance Portability and Accountability Act) regulations, and will be destroyed within 12 months. Following our clinical review of the referral information, and according to your informed consent, we will contact you for an informational telephone screening. If we are unable to provide treatment services for you, we will assist you in identifying resources and/or information appropriate to your specific situation. Items in red are required fields. Client's First Name: Client's Last Name: Age: Male Female Behaviors: Disability Type/Diagnosis: Emotional Developmental Mental Health Behavioral Physical Alcohol or Drug use issues Learning Other Comments: Service(s)/Information Wanted: Residential Respite Education Day Programming Don't Know Comments: Health Concerns: Diabetes Asthma Obesity Blood Pressure Other Comments: Where do you Live? State: Illinois Indiana New Jersey South Carolina Wisconsin City: Zip Code: Your Contact Information Your First Name: Your Last Name: Agency: Email: Phone Number: How did you Learn About us? Internet Friend Agency School Parent Service Directory Other Comments: What is your Relationship to the Person with Service Needs? Parent Guardian Family Self Friend Teacher Professional Other Comments: Leave Feedback: