Making Referrals to AOC Outreach Services

Your healing journey begins with our simple online enrollment form. Please provide us with the client's personal information to start the initial enrollment process. Once you have submitted all required information below, your request will be reviewed by an AOC Intake Specialist. 

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Heads Up!

You will need the following information to submit your referral:

Child or Patient Details:
  • The full name of the child or patient
  • The date of birth of the child or patient
  • The social security number for the child or patient
  • The child or patient's home address
Legal Guardian/Parent Details:
  • The Guardian/Parent full name
  • The Guardian/Parent phone number
  • The Guardian/Parent personal email address
Health Insurance Details:
  • The child's insurance provider
  • The child's insurance policy number 
Medical Details:
  • The name of the child's medical doctor or primary care provider
  • The name and dosage of current medication prescriptions (If Any)
Educational Background:
  • The name of the child's school
  • The address of the child's school
  • The child's current grade level

 

New Client Enrollment Form