Residential Referral Form

Filling out and submitting the form below is your first step toward completing a referral for the Residential Program (QRTP) at Cincinnati Children's.
The second step is sending a separate email to this address residential.referrals@cchmc.org with additional patient related materials to support a patients admission consideration.
Additional information to be sent as part of step two in completing this referral:

1. Attach in your email clinical documentation from past mental health treatment for review. We are looking to see the progression of illness, engagement in treatment, and staff/peer interactions. This would include, but is not limited to: Assessments, ETR/IEP, therapy notes, inpatient treatment daily notes, CANS, etc.
2. Attach a copy of the front and back of insurance or Medicaid cards.

Referrals that are submitted with all the necessary information will be prioritized. Our team will reach out using contact information you submit in the form if we have additional questions.
For more information, contact the Residential Treatment Program by calling +1-513-636-0820 or by email: residential.referrals@cchmc.org