Referral Application

Southstone Referral Form

Referring Agency




Child/Adolescent










Parent/Guardian Contact Information:







Custody:








Reimbursement:







PLEASE UPLOAD as many of the following documents as possible:
  • Most recent psychological evaluation and psychiatric evaluation.
  • Discharge summaries from previous treatment providers within last year.
  • Social history – Pre/Post Dispositional Report - Foster Care Service Plans.
  • Documents with Information describing behavior within past 2 months (treatment plans, nursing/progress notes, progress summary reports) indicating medical necessity for secure RTC treatment.