Who Can Make a Referral?

Anyone that knows the individual can make a referral. Ascent receives referrals from parents, relatives, schools, teachers, counselors, mental health professionals, probation officers, etc.  Ascent works mostly with individuals that meet the qualifying criteria through Amerigroup insurance.   

In addition, Ascent can provide standard outpatient counseling services for those who need assistance.

How Do I make a Referral?

You may submit a referral by filling out a referral form below and by clicking  "submit." For a printable version, click here. If you have questions, please contact us or call 901-206-2222. 

Next Steps

After you have submitted a referral form, you will be contacted by one of our Ascent representatives.

Submit the following form to refer a youth to Ascent Memphis.

For more information, questions, or to speak an Ascent Representative, e-mail Taysha Hilson at or call 901-206-2222.

Today's Date *
Today's Date
Youth Name *
Youth Name
Date of Birth
Date of Birth
Legal Guardian's Phone 1 *
Legal Guardian's Phone 1
Legal Guardian's Phone 2
Legal Guardian's Phone 2
Address *
(Ex. Agency Name, Family Friend, Teacher, Relative, etc.)
Contact Phone Number *
Contact Phone Number