Make A Referral

Professionals who make referrals to Portage Path Behavioral Health, such as physicians, counselors, social workers, law enforcement/legal professionals, and social service employees are able to use this feature to begin the process of making a referral to portage Path Behavioral Health. 

The only information we are able to provide you with about your patient's / client's treatment at Portage Path is whether or not they showed up for their first (Intake) appointment.  You will receive a response in the mail with this information.  If you think you will require ANY additional information about your patient / client, please take a moment now to download a copy of our Release of Information form.  This form can be found under the For Referral Sources drop-down menu at the top of this page.

Also, please know that experience has shown us that frequently individuals do not follow through with the referral made by a professional like yourself.  You can help make sure your patient / client gets the help they need by reinforcing the importance of making and keeping their appointment, and by reminding them that you will know whether or not they made / kept the appointment.

To make a referral, just fill in the fields below, and a Portage Path admissions specialist will call your client to obtain more information and schedule an Intake appointment.



Please provide us with the following information to get started with the referral process.


About The Referral Source:

Referral source name:
Referral source address:
Referral source phone:
Referral source email:
About the Patient:

Social Security Number:
Name:
Address:
Daytime Phone Number:
Date Of Birth:
Sex: Male Female
Marital Status: Single Married
  Divorced Widowed
Reason for referral:(Please type your explaination in the box below.)

Mental health issues observed:(check all that apply)

Depression Anxiety Mood Swings

  PTSD Eating Disorder Psychosis
  Anger OCD Marital/Relationship

Other issues noted or observed:(check all that apply)

Substance Abuse Legal Housing

  Financial Agression
  Other issues observed: (Please list)
Previous psychiatric treatment:(check all that apply)

Inpatient Outpatient Substance

  Past Portage Path client Past CSS client

Recommended MH services or programs:(check all that apply)

Psychiatric Med./Somatic


  Individual Psychotherapy Group Treatment
  Brief Treatment Anger Management
  Coping Skills/DBT Dual Diagnosis/SAMI
  Sex Offender Treatment Partial Hospitalization
  Group Program: (list which one)
Current medications & prescribing MD:(Please type your explaination in the box below.)

Alcohol use/abuse: Yes No
Illegal drug use/abuse: Yes No
Financial information: Medicaid Medicare Self pay
  Medical Mutual Other:
 Please Note: Portage Path Behavioral Health is NOT able to accept many private insurance programs. Please call us at 330.253.3100 to find out more information

Release of information: Release form completed and mailed
  Release pending
  No release
 Please Note: To download our Release of Information Form, and to view instructions for completing the release, please visit the page titled Releases of information (under the For Referral Sources menu) after finishing this form.

Click button to submit:

  About Your Confidentiality