Our new center is under construction — see the progressOur new center is going up

Preliminary referral form

Refer a child.

For schools, pediatricians, care managers and community organizations, and for families who would rather give us everything now. Our team reviews it, checks eligibility and insurance, and contacts you about the next steps.

Go to the formParent? Start with the short form

Before you start

Three things to know.

  • This is not an official intake or enrollment form. Nothing is decided here.
  • If you are a professional, put your own name and role under “person completing this form,” and make sure the parent or guardian knows and agrees.
  • Insurance details are sent over an encrypted connection to our intake team only. Questions: 845-459-0008. Professionals can also email intake@risingchildcenter.org.
  • New to referring? How referrals work, and what paperwork helps.

Preliminary referral form

Please complete this short form so our team can review the request and contact you regarding eligibility and the next steps. This is not an official intake or enrollment form.

Child’s information
Contact information
Preferred method of contact
Service requested

Select the service you are interested in. You may select more than one.

Mental health services

ABA services

Reason for referral
Insurance information
Does the child have Medicaid?
Photos or PDF. You can choose two files, up to 4 MB together; large photos are shrunk for you.
How did you hear about us?
Authorization

Sent over an encrypted connection to our intake team. If your child is in immediate danger, call 911. For a mental health crisis, call or text 988.