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Option to Success Inc. – Referral Form

Client Information

Client Name:

Date of Birth:

Phone Number:

Parent/Guardian (If Under 18)

Name:

Phone Number:

Referral Source

Name/Agency:

Phone or Email:

Program Requested

Reason for Referral

Safety or Immediate Concerns

None

Yes

If Yes

Privacy & Consent

The information you provide on this form is confidential and is used solely to evaluate and process this referral for services at Option To Success Inc. It will be shared only with OTS staff directly involved in reviewing the referral and, where applicable, with the referring agency or provider named above.

Submitting this form does not enroll the individual named above as a client of Option To Success Inc. and does not guarantee admission into any program.

All information submitted is transmitted and stored securely. For full details on how we collect, use, and protect your information, please read our Privacy Policy.

Consent

I have read and understand the Privacy & Consent statement above, and I consent to the submission of this information for referral purposes.

General Inquiries

Telehealth appointments are available