Forms for Referral

In order to refer a child to Orchard Place, the

Referral Application, the Bio/Psycho/Social Assessment and the Placement Agreement need to be completed by the parent or guardian.

The Authorization for Release of Professional Information form must be completed for current and previous treatment or services providers and for all insurance and/or Medicaid. The form allows us to obtain records for the child and to contact insurance companies regarding benefits. Please complete one for each professional or agency who has worked with the child including the county DHS office (i.e. “Polk County DHS”) or Juvenile Court Office (i.e. “Warren County Juvenile Court”). They are considered the Health Care Provider and Orchard Place is the recipient. You may also sign a release at the office of the other treatment provider. Records can be faxed or mailed to us, please visit our contact page for details.