Need help? We're here for you 24/7. Call us: (501) -664-4308
Contact
En Español
COVID-19
About
About Us
Board of Directors
Executive Leadership
Locations
Little Rock - 12th Street
Little Rock – Merrill Drive
Little Rock – Freeway Medical Tower
Monticello
Services
Therapeutic Communities
Crisis/Emergency Services – Available 24/7
Outpatient Counseling Services – Children & Adolescents
Outpatient Counseling Services – Adults
Residential Treatment – Children & Adolescents
Therapeutic Foster Care
Human Trafficking Treatment
Family Centered Treatment (FCT)
Pharmacy
Primary Care
Careers
Events
Foundation
Ways to Give
About Us
Board of Trustees
Volunteer
Champions of Hope
Events & Fundraisers
Our Donors
DONATE
our services
Save the Date: Evolve Gala Saturday, April 18, 2026
contact us
learn more
About
this Service
Referral Information
Date of Referral (Required):
Person Requesting Services (Required):
Parent/Guardian
Teacher
School Personnel
DHS
Probation
State Entity
Other
Person Completing Form (Required):
Relationship to Client:
School:
School District:
Grade:
504 Plan
IEP
Gender:
Male
Female
DOB:
Age:
Social Security Number:
Parent/Guardian Name (Required):
Address:
City:
State:
Zip:
Email:
Main Phone (Required):
Work Phone:
Phone Number of Person Completing Form (Required):
Living Arrangements:
w/ Family
Foster Family
Other
Other Living Arrangements:
Need for Interpretive Services:
Yes
No
Specifics:
Aggression
Impulsive
Sadness
Family Concerns
Fighting
Distracted
Excessive Worry
Poor Hygiene
Defiant
Hyperactive
Withdrawn
Attendance Issues
Disruptive
Poor Boundaries
Startles Easily
Excessive Lying
Sexual Acting Out
Poor Peer Relationships
Poor Appetite
Stealing
Poor Peer Relationships
Sexual Language
Inattentive
Excessively Tired
Brief Explanation of Concerns:
FUNDING SOURCE
MCO/Passe:
Member ID:
Primary Private Insurance Name:
Insurance Plan No:
Group #:
Other:
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
Referral Information
Date of Referral (Required):
Person Requesting Services (Required):
Parent/Guardian
Teacher
School Personnel
DHS
Probation
State Entity
Other
Person Completing Form (Required):
Relationship to Client:
School:
School District:
Grade:
504 Plan
IEP
Gender:
Male
Female
DOB:
Age:
Social Security Number:
Parent/Guardian Name (Required):
Address:
City:
State:
Zip:
Email:
Main Phone (Required):
Work Phone:
Phone Number of Person Completing Form (Required):
Living Arrangements:
w/ Family
Foster Family
Other
Other Living Arrangements:
Need for Interpretive Services:
Yes
No
Specifics:
Aggression
Impulsive
Sadness
Family Concerns
Fighting
Distracted
Excessive Worry
Poor Hygiene
Defiant
Hyperactive
Withdrawn
Attendance Issues
Disruptive
Poor Boundaries
Startles Easily
Excessive Lying
Sexual Acting Out
Poor Peer Relationships
Poor Appetite
Stealing
Poor Peer Relationships
Sexual Language
Inattentive
Excessively Tired
Brief Explanation of Concerns:
FUNDING SOURCE
MCO/Passe:
Member ID:
Primary Private Insurance Name:
Insurance Plan No:
Group #:
Other:
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
Referral Information
Date of Referral (Required):
Person Requesting Services (Required):
Parent/Guardian
Teacher
School Personnel
DHS
Probation
State Entity
Other
Person Completing Form (Required):
Relationship to Client:
School:
School District:
Grade:
504 Plan
IEP
Gender:
Male
Female
DOB:
Age:
Social Security Number:
Parent/Guardian Name (Required):
Address:
City:
State:
Zip:
Email:
Main Phone (Required):
Work Phone:
Phone Number of Person Completing Form (Required):
Living Arrangements:
w/ Family
Foster Family
Other
Other Living Arrangements:
Need for Interpretive Services:
Yes
No
Specifics:
Aggression
Impulsive
Sadness
Family Concerns
Fighting
Distracted
Excessive Worry
Poor Hygiene
Defiant
Hyperactive
Withdrawn
Attendance Issues
Disruptive
Poor Boundaries
Startles Easily
Excessive Lying
Sexual Acting Out
Poor Peer Relationships
Poor Appetite
Stealing
Poor Peer Relationships
Sexual Language
Inattentive
Excessively Tired
Brief Explanation of Concerns:
FUNDING SOURCE
MCO/Passe:
Member ID:
Primary Private Insurance Name:
Insurance Plan No:
Group #:
Other:
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
Referral Information
Date of Referral (Required):
Person Requesting Services (Required):
Parent/Guardian
Teacher
School Personnel
DHS
Probation
State Entity
Other
Person Completing Form (Required):
Relationship to Client:
School:
School District:
Grade:
504 Plan
IEP
Gender:
Male
Female
DOB:
Age:
Social Security Number:
Parent/Guardian Name (Required):
Address:
City:
State:
Zip:
Email:
Main Phone (Required):
Work Phone:
Phone Number of Person Completing Form (Required):
Living Arrangements:
w/ Family
Foster Family
Other
Other Living Arrangements:
Need for Interpretive Services:
Yes
No
Specifics:
Aggression
Impulsive
Sadness
Family Concerns
Fighting
Distracted
Excessive Worry
Poor Hygiene
Defiant
Hyperactive
Withdrawn
Attendance Issues
Disruptive
Poor Boundaries
Startles Easily
Excessive Lying
Sexual Acting Out
Poor Peer Relationships
Poor Appetite
Stealing
Poor Peer Relationships
Sexual Language
Inattentive
Excessively Tired
Brief Explanation of Concerns:
FUNDING SOURCE
MCO/Passe:
Member ID:
Primary Private Insurance Name:
Insurance Plan No:
Group #:
Other:
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
Referral Information
Date of Referral (Required):
Person Requesting Services (Required):
Parent/Guardian
Teacher
School Personnel
DHS
Probation
State Entity
Other
Person Completing Form (Required):
Relationship to Client:
School:
School District:
Grade:
504 Plan
IEP
Gender:
Male
Female
DOB:
Age:
Social Security Number:
Parent/Guardian Name (Required):
Address:
City:
State:
Zip:
Email:
Main Phone (Required):
Work Phone:
Phone Number of Person Completing Form (Required):
Living Arrangements:
w/ Family
Foster Family
Other
Other Living Arrangements:
Need for Interpretive Services:
Yes
No
Specifics:
Aggression
Impulsive
Sadness
Family Concerns
Fighting
Distracted
Excessive Worry
Poor Hygiene
Defiant
Hyperactive
Withdrawn
Attendance Issues
Disruptive
Poor Boundaries
Startles Easily
Excessive Lying
Sexual Acting Out
Poor Peer Relationships
Poor Appetite
Stealing
Poor Peer Relationships
Sexual Language
Inattentive
Excessively Tired
Brief Explanation of Concerns:
FUNDING SOURCE
MCO/Passe:
Member ID:
Primary Private Insurance Name:
Insurance Plan No:
Group #:
Other:
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
We're here for you 24/7—ready to assist whenever you need us
Email us today
other services
You may also
be interested
in
Outpatient Counseling Services – Adults
Residential Treatment – Children & Adolescents
Crisis/Emergency Services – Available 24/7
Outpatient Counseling Services – Children & Adolescents
Stay up to date on our events
Subscribe to Our Newsletter
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
@thecentersar
We're on
Facebook!
View Facebook Page
