Referral requests are fulfilled in 5-10 business days.  If this is an urgent request, please let us know by including that information in the Notes box below.
ATSA does not license, certify, or endorse individuals or organizations. All ATSA members have met the requirements for ATSA membership. To view ATSA’s membership requirements, click here.

Referral Request:

Your Name (optional):

 

How should we deliver the referral?

One delivery option must be completed for us to send the referral.

Email address:

Fax:

Phone:

If you would prefer that we mail the referral, please use the Notes box below to include your mailing address.

 

Location for treatment referral?

City:

State: - None -(U.S.) Virgin IslandsAlabamaAlaskaAlbertaAmerican SamoaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFed. States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundland and Labrador   North CarolinaNorth DakotaNorthern MarianasNorthwest Territories  Nova ScotiaNunavutOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandPuerto RicoQuébecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukon Territory

Zip/Postal Code:

 

Referral Type:

select all that apply

Alcohol/Drug Abuse

Civil Commitment Evaluations/Treatment

Community Outpatient

Employment or Housing Advocacy/Services

Faith-based Sex Offender Treatment

Polygraphy

Program for Non-adjudicated Offenders

Psychiatric Hospital

Psychosexual Forensic Evaluation

Residential

Victim Advocate

 

Population Served:

select all that apply

Adult Males

Adult Females

Adolescent Males

Adolescent Females

Pre-pubescent Males (12 and under)

Pre-pubescent Females (12 and under)

Developmentally Disabled Adults

Developmentally Disabled Adolescent

Hearing Impaired

Abuse Reactive Children

Families of Adolescents/Children who Offend

Family/Spouse of Adults who Offend

 

Secondary Language (Spanish, etc.):

 

Physiological Assessment:

Physiological Assessment

PPG

Viewing Time

 

Notes:

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