CONTACT US 
Got Referrals? Contact Us!
    
Phone: 704-603-8285    Fax: 704-353-7901  Website: SHYAS.COM
  909 S. Main St. Suite 208
   Salisbury NC 28144

           Download a referral form      
Referrals may be Faxed to 704-353-7901  *  Referrals may also be emailed
             
People@shyas.com
           
                    
                       
or you may complete the referral form below  
                Please be sure to complete each section of the referral form

Download Load Referral Form by clicking on the link

S&H Youth and Adult Services, Inc.
Referral Form

   

Date:
Name of person referred:
 Address of the referred:
City, State, Zip Code:
Phone Number:
Does the Referred have Medicaid  Yes or No

Known Psychiatric Diagnosis:

Current Medications:
Brief Description of referred presenting problem:
Is this a self referral Yes or No
Name, Title, & Organization of referring party:
Contact Number of Referring Party
(Office & Cell):
Recommended Service:
(DWI, Foster Care, or Outpatient Services)

S&H Youth and Adult Services, Inc.

Coaching, Counseling, & Consulting

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