Child Referral Form for the MT Rural Telemental Health Program

This form is to be completed by the referrer (i.e., victim advocate, CPS worker, etc.) to refer a child for therapy via telemental health through the Montana Rural Telemental Health Program. Please verify with the child and caregiver that they are interested in therapy before making a referral. 

A copy of this form will be submitted to the Children's Alliance of Montana's (CAM) Montana Rural Telemental Health Program, which will use it to identify a therapist. After identifying the therapist, CAM will connect the therapist and referrer for a conversation about the child. 

Once you begin this form, you must complete it in one sitting. You will see a confirmation message at the end of the form once the form has been successfully submitted. If you do not see this message, your form has not been submitted. Please contact the program coordinator at rtmhp@childrensalliancemt.org if you have any questions.