Make a Referral

Make a Referral – Outpatient Behavioral Health Services

To make a referral for Behavioral Health Services please complete the online referral form below. Once submitted an IMPOWER staff member will contact you.

Submit a Referral for Me or My Child (Dependency Case Managers Use This Form)

Online Referral Form for Self/Parent or Guardians

Submit a Referral for Someone Else (Providers please use this link)

Online Referral for Providers

Download a Referral Form

Referral Form (PDF)

Referral Form (Spanish/Español PDF)

Please print, complete and return downloaded form by mail, email or fax to the address on the referral form.
Note: Adobe Acrobat Reader is required to view PDF files.

If you are experiencing an emergency, dial 911. If you are in crisis and need someone to talk to, dial 211.

For Existing Clients

If you are already an IMPOWER client, and need to schedule an appointment for mental health, psychiatric services or medication management please contact our Centralized Referrals and Scheduling Department  by phone at 321.639.1224 option 2; or email at