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

           Download a referral form      
Referrals may be Faxed to 704-353-7901  *  Referrals may also be emailed
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


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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