Limited data security incident reported by CPS Solutions, a hospital partner. Learn more.

X

Search

popular searches

close   X

main phone 937-641-3000 emergency department 937-641-3600 scheduling 937-641-4000
Location Phone Numbers All Department Phone Numbers contact us
searchclose
locations
contact
menuclose

home // patients & visitors // services // behavioral health // specialties // outpatient therapy // outpatient therapy self-referral

outpatient therapy referral questionnaire

This page is not frequently monitored. If your child is experiencing a mental health crisis, please call 911 or go to an emergency department.

Has the patient had outpatient counseling?
Has the patient had medication management?
Does the patient have a history or current Autism Spectrum Disorder (ASD) Diagnosis?
Does the patient have a history or current substance use disorder diagnosis?
Does the patient have a history or current oppositional defiance or conduct disorder diagnosis?
In the past three months, has the patient made any threats or attempts to hurt self or others?
In the past three months, has the youth tried to cause or has he/she caused physical injury (including sexual) to another person or against property?
Are there any current legal charges related to hurting others or the destruction of property?
Do you have concerns that the patient may hurt others during his/her treatment?
04/16/25 | blog post measles: what every parent needs to know right now keep your child safe from measles with MMR vaccine
05/23/25 | blog post meet our newest (and furriest!) member of the mental health team Meet Piper, our newest facility dog, bringing comfort and connection to patients at the Mathile Center for Mental Health and Wellness

Jayden Clark

Difficulty breathing leads Jackson on a journey to a rare diagnosis.

learn more