Contact Lighthouse School-Based Services

Lighthouse Youth & Family Services is here to help. Complete the form below, call, or send an email. We’ll get back to you as quickly as possible.

Please note: Email messages from the website are not monitored by our clinical staff. If you have an emergency, please call 911.

Are you referring for yourself or on behalf of someone else?*
- Myself/My Child
- Someone Else
If you are submitting a referral on behalf of someone else, is their legal guardian aware the referral is being made?
- Yes
- No
- N/A
Contact Name*
First Last
Contact Email*
Contact Phone Number
Young Person's Name*
First Last
Young Person's Date of Birth*
Month
Day
Year
Legal Guardian's Name if young person is under 18*
First Last
Legal Guardian's Phone Number
Legal Guardian's Email*
Relationship of Legal Guardian to Youth
Service or services requested
Supporting File/s: Do not share documentation containing protected health information
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