Referral Form

Please do not complete this form if you are under 16 years old or considered a minor based on your age and state. We would need your parent/guardian to provide consent to have your personal data, such as Name, Phone Number, and Email address. Please ask your parent/guardian to complete this form, and we will contact them. If you or your child are in a crisis, or any other person may be in danger – please don’t wait for a callback. Proceed to your nearest emergency room or call 911. This form is monitored during office hours and is not intended to provide crisis services. Someone will contact you the next business day. These resources may also be helpful. By providing your mobile number and e-mail address, you consent to receive communication from Lumate via phone and e-mail. Digital communications sent over unencrypted networks may not be secure.