Referral for FSGC Services

Complete the information below. Be sure to click "Submit" to send your form to us. FSGC Admissions will contact the child’s parent/legal guardian to set up an appointment. (NOTE: An asterisk * indicates required information.)

NOTE: Family Service & Guidance Center will only contact the family if services have been discussed with them prior to the submission of this form.


Referrer Information


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Family Service & Guidance Center
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Family Service & Guidance Center was founded in 1904 to help local flood victims. Today, FSGC is one of the Midwest’s leaders in children’s mental health care.