Professional Partners Portal

Referral Partner & Agency Portal

Streamlined Support for Courts, Probation, and Community Agencies

At The Stone Community Health Center, we value our partnerships with Arizona's justice and community systems. Use this secure portal to submit referrals, verify program completion, or download official forms. All submissions are encrypted and automatically sent to our administrative email: [email protected].

Submit a Referral Verify Completion Download Forms

Available Programs

We Accept Referrals For the Following Programs

DUI Education & Treatment

Court-approved assessments and online/offline classes meeting Arizona MVD requirements.

Domestic Violence Intervention Program

Certified classes addressing accountability, relationship skills, and emotional regulation.

Anger Management Program

Evidence-based anger control, communication, and cognitive restructuring sessions.

Substance Abuse Education & Treatment

Outpatient recovery services with group and individual therapy components.

Intensive Outpatient Program (IOP)

Structured behavioral health treatment, ideal for step-down or ongoing care.

Reentry Support Program

Transitional services for justice-involved individuals focusing on counseling, employment, and reintegration.

Primary Care Services

For medical screenings, lab work, and integrated care coordination.

Download Full Program List

Form A

TSCHC Referral Form

Client Intake & Program Enrollment

For courts, probation officers, or partner agencies to refer new clients.

Download PDF Version

Agency Information

Referring Agency Name *

Officer / Case Manager Name *

Title / Department

Phone *

Email *

Date of Referral *

Client Information

Client Full Name *

Date of Birth *

Gender

Client Phone

Client Email

Client Address

Program & Case Information

Program(s) Requested *

DUI Education & Treatment Domestic Violence Intervention Anger Management Substance Abuse Education & Treatment Intensive Outpatient Program (IOP) Reentry Support Program Primary Care Services

Referral Reason / Case Summary *

Court-Mandated?

Case Number

Court Contact

Preferred Start Date

I confirm this referral is submitted with client consent and in compliance with HIPAA / 42 CFR Part 2. *

After Submission:

Thanks! Your referral was received. Our intake team will contact the client within one business day.

Form B

Program Verification Request

For courts and agencies to confirm a client's enrollment or completion.

Download PDF Version

Agency Name *

Officer / Case Manager *

Email *

Phone

Date of Request *

Client Full Name *

Date of Birth *

Case / Docket Number

Program *

Verification Type *

Enrollment Progress Completion

Preferred Delivery Method *

Completion Date (If known)

Processing Time:

Verification requests are reviewed by our administrative team within one business day. You will receive an email confirmation once verification is complete.

Form C

Agency Information & Partnership Sheet

Optional Onboarding - Register as a new referral partner

Download PDF Version

Agency Name *

Agency Type *

Primary Contact Name *

Email *

Phone

Mailing Address

Preferred Communication Method

Expected Referral Volume

We agree to TSCHC confidentiality and compliance standards (HIPAA / 42 CFR Part 2). *

Form D

Release of Information (ROI)

Client authorization for TSCHC to communicate with referring agencies

Download PDF Version

Client Information

Client Name *

Date of Birth *

Client Phone

Recipient Agency Information

Recipient Agency / Court *

Officer / Case Manager

Contact Phone

Contact Email

Fax (if applicable)

Disclosure Authorization

Purpose of Disclosure *

Information to Disclose *

Attendance Records Assessment Results Progress Updates Completion Certificate

Expiration Date *

I understand I may revoke this authorization in writing at any time. *

Client Signature (Type Name) *

Signature Date *

Privacy Notice

Protected by HIPAA and 42 CFR Part 2. Do not share without authorization. This form authorizes disclosure of protected health information only as specified above.

Forms Library

Downloadable Forms

Download all four fillable PDFs for agencies preferring offline submission. All completed forms can be emailed to [email protected].

Referral Form

Client intake & enrollment (PDF)

Download PDF

Verification Form

Program verification request (PDF)

Download PDF

Agency Info Form

Partnership registration (PDF)

Download PDF

Release of Information

Client authorization (PDF)

Download PDF

Download All Forms (ZIP)

Contact Directory

Program Coordinator Contacts

For direct coordination or urgent matters, please contact the appropriate program lead.

Program	Coordinator / Department	Email
DUI / Substance Abuse	Behavioral Health Coordinator	[email protected]
Domestic Violence / Anger	Clinical Program Director	[email protected]
IOP / Reentry Support	Case Management Team	[email protected]
Primary Care	Medical Services	[email protected]

Email a Coordinator

Compliance & Confidentiality

All referral and verification data submitted through this portal are protected under HIPAA and 42 CFR Part 2 confidentiality laws.

TSCHC ensures that all client and agency communications remain private, secure, and compliant with Arizona behavioral health regulations.

HIPAA Compliant

42 CFR Part 2

AZ Certified

View Privacy Policy

Partnership Opportunities

Partner With The Stone Community Health Center

Together, we can make lasting change. Partner with TSCHC to connect your clients to compassionate care that builds accountability, recovery, and resilience.

Submit a Referral Contact Our Team

Visit Us

423 N Country Club Drive
Suite 45
Mesa, AZ 85201

Call Us

(480) 659-6359

Office Hours

Monday – Friday
9:00 AM – 4:30 PM

"At The Stone Community Health Center, your health — body, mind, and spirit — matters."

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