Referring Professionals

Our dedicated team and support staff are committed to providing you with the help you need. To make a referral, please fill out the form below, and one of our support staff will get in touch with you.

Intake/Referral Information

"*" indicates required fields

Referred Client*

First Last

Date of Birth*

MM slash DD slash YYYY

Contact Name (Parent/Guardian/Caregiver)

First Last

Contact Phone*

Is it OK to leave a message or text message?

Yes

Contact Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Service Request (check all that apply)

Counseling

Psychiatry/Medication Evaluation

Type of visit (check all that apply)

Telehealth (Video Conferencing)

In Office

School

If “In Office” do you have a preference of Office Location?

431 E Broad Street

Cleveland Ave

E Main Street

Middletown

School (if we offer service in your school)

Name of School

Referral Contact Name

Phone

How did you hear about UMCH Family Services?

Need immediate help? Call (614) 885-5020

UMCH Family Services is a comprehensive mental health and child welfare agency that helps families stay together, reunify or become new permanent families. We have worked with thousands of children and parents across Ohio through Treatment Foster Care, Outpatient Mental Health Services, Psychiatry, Intensive Home-Based Treatment, and Adoption.