Home › Referrals › Fill it online
This is the official AIMH-FRM-040, filled on screen. Nothing to print, nothing to download first. When you send it we build the signed PDF, give you a reference number, and email you a copy.
Preferred language for the family
Our team works in English and Spanish. For any other language we arrange a qualified interpreter at no cost to the family.
Family knows about this referral
Diagnosis status
Behaviors, skills, communication, recent changes — anything that helps us triage.
Referral source
Check anything present. This is what moves a referral up the list.
Safety concerns
Urgency
Services
Attached with this referral
PDF, JPG or PNG · up to 5 files, 4 MB each. Send what you have — our intake team chases the rest with the family.
Two ways to sign — either one is enough.
✍️ Draw it here — mouse, trackpad or finger
📱 Or sign on your phone
Press the button to get your code.
Scan it, draw with your finger and send. It appears here on its own. The link lasts 15 minutes.
Signature received
Signing records your name, the date and time with your time zone, this page, your browser and — only if you tick the box — your coordinates. Under the E-SIGN Act this signature has the same legal effect as one on paper.
Optional — you can send the form without agreeing to text messages.
Prefer paper? Download the PDF, fax it or email it →