Placement & Services Inquiry
Care coordinators, guardians, social workers, and facilities can use this form to request placement or services.
Disclaimer and Consent for Information Sharing
By completing this form, you acknowledge that the information provided may contain Protected Health Information (PHI). The Charles Henry Center will use the information submitted solely for the purpose of reviewing the referral, determining potential service eligibility and availability, and coordinating next steps related to services.
The Charles Henry Center is committed to protecting the privacy and confidentiality of the individuals we serve. Information submitted through this form will be handled in accordance with applicable privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA), when applicable.
Submitting this inquiry does not guarantee acceptance, placement, or admission into services with The Charles Henry Center. All referrals are subject to review to determine whether our programs can appropriately meet the individual’s needs and whether the requested service is available.
Additional clinical documentation may be required to complete the referral review. Clinical records and supporting documentation should be submitted separately as instructed by The Charles Henry Center.
By checking the box below, you confirm that you have read and understand this disclaimer and that you are authorized to provide the information included in this referral inquiry.
Having trouble with the referral form? Contact us at admin@thecharleshenrycenter.com.
Please read and agree to the terms above to open the inquiry form.