Self/Others Referral Form

Complete this form, or call 800-75-SEALS, to refer yourself or another individual for services at Easterseals MORC.

Complete this information for the person making the referral

First Name

Last Name

Phone

Email Address

Relationship to person being referred for services

Referring Agency, if applicable

If Relationship is "Other" describe here:

Mental Health Screening - Crisis Only

School District

School Building (Avondale)

School Building (Berkley)

School Building (Birmingham)

School Building (Bloomfield)

School Building (Brandon)

School Building (Center Line)

School Building (Clarenceville)

School Building (Clarkston)

School Building (Clawson)

School Building (Farmington)

School Building (Fenton)

School Building (Ferndale)

School Building (Fitzgerald)

School Building (Grand Blanc)

School Building (Hazel Park)

School Building (Holly Area)

School Building (Huron Valley)

School Building (Lake Orion)

School Building (Lamphere)

School Building (Madison)

School Building (Novi Community)

School Building (Oakland)

School Building (Oak Park)

School Building (Oxford)

School Building (Pontiac)

School Building (Rochester)

School Building (Royal Oak)

School Building (South Lyon)

School Building (Southfield)

School Building (Troy)

School Building (Van Dyke)

School Building (Walled Lake)

School Building (Waterford)

School Building (West Bloomfield)

Other - Official School Building Name

Contact me before reaching out to person/family being referred

How did you hear about Easterseals MORC?

Complete the Parent/Guardian information of the individual being served

First Name

Last Name

Email Address

Primary Phone

Can Easterseals MORC leave a voice message at this number?

YesNo

Are text messages preferred?

YesNo

Best time to reach Parent/Guardian?

Alternate Phone

Can Easterseals MORC leave a voice message at this number?

YesNo

Are text messages preferred?

YesNo

Please attach form

Web Referral

value

Contact Information