Professional Referral

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Professional Referral

Authorized referral sources may provide initial referral information. Temperantia-KYH will review the referral and contact the participant directly to arrange intake.

Referring professional name

Title or role

Court, agency, law firm, employer, or organization

Professional email

Professional telephone number

Participant name

Case or docket number

If applicable

Preferred method of contact

Service requested

Anger ManagementDomestic Violence InterventionCourt-Referred Juvenile ProgramNot specified

Required duration or session count

If specified by the referring authority

Court date, supervision deadline, or completion deadline

If applicable

Requested documentation and reporting expectations

Describe any required reports, attendance records, completion documentation, or deadlines.

I confirm that I am an authorized referral source and that the information provided is accurate to the best of my knowledge. I understand that Temperantia-KYH will review this referral and contact the participant directly to arrange intake.