PARAGON IS HERE TO HELP.

REFERRAL FORM

About You

Which of the following best describes you?

I am interested in services for myself

I am referring another person for services (e.g., friend or family member)

I am professionally referring another person (e.g., human services, school, non-profit partner, etc.)

If applicable, what organization are you affiliated with?

First name

Last name

How can we reach you?

Preferred Method of Contact

Your Email Address

Your Phone Number

*By providing my phone number I agree to receive calls or texts about my inquiry. For Crisis needs call 988 or 844-493-TALK. I may opt out of text messages by replying STOP. I may reply to a text message with HELP for more information. This site is monitored during routine business hours. Message and data rates may apply. Message frequency varies. Paragon does not disclose personal health information. Review our privacy policy at the bottom of our page to learn how your data may be used.

Best time to contact you:

Potential Client Information:

First & Last Name

What county does the client live in?

Client's Email

Client's Phone Number

Client's Date of Birth

Month

Day

Year

If applicable, what is the client's Medicaid or CHP+ number?

If applicable, please upload an authorization form.

What services might be a good fit for the client?

Comments/ Questions