Referral Form

Interested in scheduling a free 30-minute consultation? Please fill out our referral form and one of our counselors will reach out to you to schedule your consultation!

Click below if you’re filling out a referral form for yourself.

For myself

Click below if you’re filling out a referral form on behalf of someone else.

For someone else

I am filling out a referral form for myself

Name *

First

Last

Phone Number *

Email *

What method of contact do you prefer? *

Phone Call
Email

Gender *

Age *

Reason for Referral (please identify specific symptoms and length of time they have been present) *

Treatment History *

Have you seen a mental health provider before? *

Yes
No

If you answered yes above, please provide details on providers seen, timeframes, and medication history. If you answered no, write n/a. *

Availability for Appointments (please include days of week and times of day that work best for scheduling appointments) *

Additional Information (please include specific requests or any other relevant information you would like to share with your counselor)

Questions for us? (Please refer to our policies page in our main menu for additional information on billing, insurance, scheduling, etc)

I am filling out a referral form on behalf of someone else

Your Name *

First

Last

Relationship to Potential Client: *

Your Phone Number *

Your Email *