Ellis Human Development Institute

Referrals and Forms for Professionals

Thank you for referring your clients to the Ellis Human Development Institute. We accept referrals for evaluation and counseling for children, adolescents, and adults.  At this time, we do not offer psychiatry or case management services. We accept CareSource and offer a sliding scale for clients without CareSource. Please use the following tools in order to help us to best serve your clients.

Physician, Medical Office, and Mental Health Provider Referrals

You may fax your referral form to (937) 775-4311:

  • Ellis Referral Form (PDF): Download and print our standard referral form when referring patients to the Ellis Institute. The referral form must be accompanied by the release of information form.
  • Release of Information Form (PDF): Download and print our standard release of information form when referring patients to the Ellis Institute. The release of information form must be sent with the referral form.

Montgomery County Department of Job and Family Services Children Service Division Referrals

The MCDJFS-CSD Referral Packet (PDF)  is an online version of the information needed to refer a child who is in the custody of the Children Service Division. Download and complete this packet when referring children to us and send to:

Ellis Human Development Institute
9 N. Edwin C. Moses Blvd.
Dayton, OH 45402


Fax to (937) 775-4311

After we have received the completed MCDJFS-CSD Referral Packet (PDF), we will contact the caseworker to schedule an intake appointment. If you have any questions about completing the packet or prefer to have the packet mailed to you, please call (937) 775-4300.