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You will be contacted within 2-business days.

This is only for non-emergency related services. If you are experiencing any physical or mental health emergency, please dial 9-1-1 or head to the nearest hospital
If you are referring a patient from a health care practice, please do not submit this form and instead contact the desired clinic directly. 

We apologize for any inconvenience. Our system is currently down, please check in at a later time for an update.

Patient or Parent/Guardian
If available
Is this referral coming from a school site or school district?
*Teen Wellness offers confidential family planning & contraceptive counseling, free for those who qualify (Ages: 12+)
Only if applicable
Please do not include any personally identifiable information in this section (i.e. DOB, Social Security Number, Medical Record Number or Insurance Information)
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