Confidential Referral Form

For referral and intake, call our confidential line at 615-983-6803 or fill out the form below!

Referring Agency*
Date Referred*
MM slash DD slash YYYY
Agency Contact Name*
Title
Email:*
Agency Phone*
Client Name*
Client Phone Number
Address*
Street Address City State ZIP Code
School Name (if applicable)
Guardian Name*
Phone*
Relationship To Client
Reason For Referral
Please provide a brief summary of the reason for the referral.
Comments
This field is for validation purposes and should be left unchanged.

STARS does not discriminate on the basis of race, color, gender, culture, religion or creed, socioeconomic status, language, age, sexual orientation, or national origin. No one shall be excluded from the participation in, be denied the benefits of, or be subject to discrimination under any of STARS’ programs or activities. STARS is an Equal Opportunity Employer.

This agency is funded, in part, by the Tennessee Department of Mental Health and Substance Abuse Services, the Tennessee Department of Education and by the Tennessee Commission on Children and Youth. This project is funded under a grant contract with the State of Tennessee.

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