Professional Referral Form

​If you wish to be included as a potential resource for our families, please help us update our referral list by completing the form below.

* Indicates required field

Name *



Field of Specialty *

Name of Practice/Organization

Title/Position





Email *

Phone Number *

Address *



Specialties/Interests *

ADHDAnxietyAutism/PDDCommunication DisordersDepressionDevelopmental DelaysEating DisordersExecutive FunctioningLearning DisordersODD/Other Disruptive Behavior DisordersPsychoeducational TestingPsychological TestingSelf-Harming BehaviorsSubstance Abuse/Dual DiagnosisTraumatic Brain InjuriesOther

Client Age Range (Check All That Apply) *

0-34-67-1313-1718-2627+

Are you accepting new clients? *

YesNo

Do you have after-school appointments? *

YesNo

Do you have weekend appointments available? *

YesNo

Choose Any

I would like to schedule a visit to Lake Michigan Academy.