Make A Referral

To refer a client to one of our Southern New Mexico clinics,


the Referral For Service Form,fill out, and submit to La Frontera

Please DO NOT make this referral if client is unaware of the referral and is unaware of the specific services that La Frontera New Mexico provides.
Within one business day of receiving the referral, a representative from a La Frontera New Mexico regional site will contact the client for more information and discuss the concerns, provide information about La Frontera and determine scheduling any screenings or evaluations to determine eligibility for services.

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    Submit Referral Form via Email, Fax or Mail
    Download form. Print. Fill out. Fax.
    You will receive confirmation from La Frontera within one business day of receiving the referral.
    (575) 647-2898

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    Download form. Fill out. Email.
    The referral form is available in a PDF, and can be completed electronically and sent via email.

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    Download form. Print. Fill out.
    Mail form to:
    La Frontera NM
    Attention: Referrals
    100 West Griggs Avenue
    Las Cruces, NM 88001

online Referral form



Address *


Line 2



Zip Code


Social Security # *

Date of Birth *

Phone Number *

Name of Referring Party or Agency Representing *

Referring Contact Phone # *

Reason For Referral

  • Choose Any
     Academic problems
     Anger management
     Behavior problems in school
     Eating disorder
  • Choose Any
     Independent living skills
     Life/social skills
     Oppositional defiance
     Parenting skills
     Peer influcence
     Poor judgement
     Problem solving
  • Choose Any
     Self-harming behaviors
     Sexual assault/abuse
     Sexual promiscuity

Substance abuse type (if applicable)

Positive Urinalysis Dates

Describe referral situation

Other services currently receiving

Release Of Information

I, (your name) *

authorize La Frontera New Mexico to report to personnel from referring agency information for the purposes of coordinating care for this referral only. I can revoke this consent at any time, but that will not affect any information during my treatment that has already taken action relying on this release. I also understand that any disclosure made is bound by part 1 of Title 42 of the Code of Federal Regulations governing confidentially of alcohol and drug abuse patient records and those recipients of this information may re-disclose it only in connection with their official duties. This authorization to use protected health information will expire one year from the date signed below, or upon the completion of treatment at La Frontera New Mexico, whichever shall first occur.

Name of Person Giving Authorization *

Date *

Parent/Guardian Giving Authorization (if applicable)


Witness *

Date *