Self-Referral & Consultation Request – A & R Treasures Health Services

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Self-Referral Form
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Home
About
Services
Self-Referral Form
Contact

Refer Yourself for Care or
Request a Consultation

Complete the form below to start your journey with A&R Treasures. Our team will review your information and respond within 1–2 business days.

How it Works

Fill Out the
Form

Tell us a bit about yourself and your needs.

We Review Your Request

Our clinical team will assess your information.

We Reach Out

You’ll receive a call or email to schedule next steps.

Connect With Us

Need support for your treasure? We’re here to help. Whether you're ready to refer someone for services or unsure if they qualify, this form allows you to start the process in a way that works best for you. Select your reason for contact below and complete the relevant sections.

Step 1: What would you like to do today?(Select one)Self-Referral – I am ready to refer a treasure for services.Request a Consultation – I’m not sure what services apply or if I can make a referral, and I would like to discuss options.

Step 2: Contact Information

This information is required for both options.

Full Name

Phone Number

Email Address

Preferred Contact Method:Phone CallTest MassageEmail

Best time to contact you?

Hours

Minutes

AM/PM

Step 3: Treasure’s Information

Required for Self-Referral; optional for Consultation Requests

Full Name

Date Of Birth

Gender

Primary Language

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Country Of Residence

School Attending (if applicable)

Any known diagnosis, concerns, or areas of need

Step 4: Services of Interest

Select all that apply or leave blank if unsure

Select all that apply or leave blank if unsure *Case Management24-Hour Residential ServicesISS (Individualized Skills & Socialization) – Support for individuals with intellectual and developmental disabilitiesSupport for Individuals with Intellectual or Developmental Disabilities (IDD)Host Home/Companion Care – Including specialized foster care for individuals with IDDEarly Intervention & Developmental ScreeningSchool Advocacy / IEP SupportEmergency Placement / Temporary CareResource Navigation or Community Referrals

Other (please describe):

Step 5: Additional Notes or Questions

Is there anything else you’d like us to know? (Optional)

Step 6: Consent & Acknowledgment

Check all boxes to submit the form *I confirm that I am the legal guardian of the individual or have appropriate permission to submit this referral or consultation request.I understand the information provided will remain private and confidentialI give A&R’s Treasures Health Services, LLC permission to review this form and contact me as indicated above.

Save as Draft

Please do not fill in this field.

Contact Help Box

❓ Need Help? If you need help completing this form, call us at 713 489 9738 or email support@artreassureshealthservices.com

At A&R Treasures Health Services, LLC, we believe that everyone deserves access to quality care, respectful advocacy, and the resources they need to live a healthy, fulfilling life.

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Services

Case Management and Advocacy
Comprehensive Health Care Services
Health Education Services
General Resource Outreach Service

Business Hours

Monday : 08.00 AM – 06.00 PM
Tuesday : 08.00 AM – 06.00 PM
Wednesday : 08.00 AM – 06.00 PM
Thursday : 08.00 AM – 06.00 PM
Friday : 08.00 AM – 06.00 PM
Saturday – Closed
Sunday – Closed

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Refer Yourself for Care or Request a Consultation