Online Form

Find Your School

Hamilton Center

For Immediate Help, call

800.742.0787

Teens
Parents
Administrators

Find Your School

Find Your School

Hamilton Center

Teens
Parents
Administrators

For Immediate Help, call

800.742.0787

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Referrals
hamilitoncenter.org
winrecovery.org
hamiltoncenterfoundation.org
trainingourcommunity.org

Referral Pathways
Online Form

PRO TIP: Bookmark this page for even faster access.

Complete our web-based referral form.

This pathway is the preferred method for Hamilton Center and is a digital version of the Hamilton Center Referral Submission Form.

All fields are required. Submissions that do not include a Parent Permission Form will not be accepted and may be required to re-submit.

Download the Parent Permission Form

Referral Information

Student's Name

First Name *

Last Name *

Student's School *

Date of Birth *

Areas of Concern

Irritability to teachers and/or peers

Withdraw from activities/isolating themselves

Self-injurious behaviors/ideations

Difficulty with attention/focus/distractibility

Difficulty or refusal to do school work

Reports of family issues impacting school

Anger or aggression

Excessive tardiness or absence

Suspected abuse

Suspected substance involvement

Please provide any other important input from school or home:

Referrer's Information

Referrer's Name

First Name *

Last Name *

Title *

Phone *

Email *

What is the best way to contact you? *

Phone

Email

Parent/Guardian Information

Parent's Name

First Name *

Last Name

Parent/Guardian Contact Number *

Parent/Guardian Email

Child's Insurance Coverage

Parent Permission Form