BBCBHS Referral Forms
BB
Battle Belle's
Community Behavioral Health Services
Referral Portal

Program Referral Forms

Select the appropriate form below. All submissions are confidential and reviewed within 2 business days.

⚖ Arizona Supreme Court · AOC Contract Referral
1
Youth / Client Information
Demographic and contact details for the referred youth
2
Referring Probation Officer
Information for the officer submitting this referral
3
Case / Docket Information
Court and case identifiers for this referral
4
Program Selection
Select all programs appropriate for this youth
5
Consent & Authorization
Required for program enrollment and service coordination
Authorization for Referral & Release of Information By signing below, the referring officer confirms that this referral is submitted in accordance with applicable court orders or probation conditions, that the youth and/or their guardian has been informed of this referral, and that information may be shared with Battle Belle's Community Behavioral Health Services (BBCBHS) for the purposes of service coordination and program enrollment. BBCBHS will maintain all client information in compliance with applicable federal and state confidentiality laws including HIPAA and 42 CFR Part 2 where applicable.
* Required fields
✓ AOC referral submitted successfully. A confirmation has been sent to [email protected]. Our team will follow up within 24–48 hours.
⚠ There was a problem submitting the form. Please try again or email [email protected] directly.
1
Client / Youth Information
Basic demographics for the individual being referred
2
Referring Party Information
Who is making this referral?
3
Program Interest
Select all programs that may be a good fit
4
Presenting Needs / Concerns
Help us understand what this person is experiencing
5
Consent & Authorization
Signature confirms authorization for this referral
Consent to Refer & Share Information By signing below, I confirm that I have obtained the client's (and/or guardian's) consent to submit this referral and share relevant information with Battle Belle's Community Behavioral Health Services for the purpose of program matching and enrollment. I understand that BBCBHS will maintain confidentiality in accordance with applicable state and federal laws. The client has been informed of the nature and purpose of BBCBHS services.
* Required fields
✓ General referral submitted successfully. A confirmation has been sent to [email protected]. Our team will follow up within 24–48 hours.
⚠ There was a problem submitting the form. Please try again or email [email protected] directly.
1
Youth / Client Information
Demographics for the individual being referred
2
Referring Organization / Agency
Information about the community organization making this referral
3
Program Interest & Fit
Select programs that align with the youth's needs
4
Presenting Needs & Background
Help us understand the youth's situation and goals
5
Consent & Authorization
Organizational authorization for this referral
Organizational Referral Authorization By signing below, the referring organization representative confirms that this referral is submitted with the knowledge and consent of the youth and/or their parent or legal guardian, and that relevant information may be shared with Battle Belle's Community Behavioral Health Services (BBCBHS) for program matching and enrollment purposes. BBCBHS will maintain all information in compliance with applicable confidentiality and privacy laws. The referring organization acknowledges that BBCBHS is not a crisis services provider and that emergency situations should be directed to appropriate emergency services.
* Required fields
✓ Community referral submitted successfully. A confirmation has been sent to [email protected]. Our team will follow up within 24–48 hours.
⚠ There was a problem submitting the form. Please try again or email [email protected] directly.
BB
Battle Belle's Community Behavioral Health Services
15331 W Bell Rd, Suite 212 · Surprise, AZ
501(c)(3) Nonprofit · [email protected]