Make a Referral

Referring Agency
Agency Name*
Referrer Name*
Address
City*
State*
Zip*
Phone*
Fax
Email*
Please download and attach our Release of Information Form and any additional documents to support your referral* (any information from the child's file, IEP info, behavioral documentation from the school, etc.)
Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, ppt, pptx, odt, avi, ogg, m4a, mov, mp3, mp4, mpg, wav, wmv.
Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, ppt, pptx, odt, avi, ogg, m4a, mov, mp3, mp4, mpg, wav, wmv.
Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, ppt, pptx, odt, avi, ogg, m4a, mov, mp3, mp4, mpg, wav, wmv.
Child Information
Child Name*
Child Date of Birth*
Gender
Guardian Name*
Child Address*
City*
State*
Zip*
Child Services Custody?*
- Yes
- No
Interpreter Needed?*
- Yes
- No
Phone Number*
Primary Language*
Programs/Services sought: (Check all that apply)
- Outpatient Family Services
- Community Family Intervention
- Hispanic/Latino Services
- Intensive Family Stabilization
- St. Vincent Preschool Prep Academy
- St. Vincent Elementary Prep Academy
- Early Childhood Mental Health
- Residential
Additional Child Info
Child SSN
Insurance Plan #
- Medicaid
- Caresource
- Molina
- Private
- Unknown
Does the child have an IEP?
- Yes
- No
- Unknown
Please share any additional relevant information:

For professional referrals, click here to download our referral form. Complete and return by email to [email protected] or fax at (614) 255-5759.

Click here to download our referral form in Spanish.

Saint Vincent Family Center
1490 East Main Street
Columbus, OH 43205
PH: (614) 252-0731
FX: (614) 252-8468

Hours:
Mon–Thu: 7:30AM – 8PM
Fri: 7:30AM – 6:30PM