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.