Online Referral

Referral Network - Online Referral

If you are the parent or guardian of a struggling child or adolescent please complete the Youth Intake Risk Assessment (Y-IRA 1.0 OPR).

Thank you for taking the time to refer a child in need. As a Cooperative Wilderness Therapy (CWT) program we work closely with professionals throughout our referral network to ensure kids get the help they need. If you would like information on becoming part of our referral network, or have questions regarding our programs, please don't hesitate to contact our Program Director at 866.232.5743 ext. 700.

Please Tell us How to Contact the Child's Family

Child's Name Age Male Female

Parent's Name Telephone Email

Please Tell us How to Contact You

Name & Title of Person Completing Form

Contact Telephone Email

Would you like information about joining our referral network?

Yes
No

Please Tell us About the Child

In the space provided below please relate the purpose of your referral: