community bEHAVIORAL health referral 


​Only clients with a Medicaid Insurance Plan as their primary insurance provider are eligible to receive mental health services by YAS. 
In order to ensure timely receipt of services all information must be filled out completely.         

INSURANCE INFORMATION

 39 years  of serving thousands of children ​& their families  throughout Franklin County and surrounding areas 

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PARENT/GUARDIAN INFORMATION

CLIENT INFORMATION

REFERRAL SOURCE INFORMATION