Referring Provider/Agency Information

First Name *

Last Name *

Agency/Organization *

Phone *

Fax

Email *

Date of Referral

Please Choose: *

Primary Care Provider

Psychiatrist

School Counselor

Case Manager

Other

Client Information

Full Name *

Date of Birth *

Gender

Contact Number *

Place of Residence *

Email *

Name of Parent/Guardian (For Minors)

Insurance Company

Insurance ID

Emergency Contact (Name & Phone Number) *

Reason for Referral

Reason for Referral *

Depression/Mood Concerns

Anxiety

Trauma/PTSD

Behavioral Concerns

Family/Relationship Issues

Grief/Loss

Substance Use

Self-Harm/Suicidal Thoughts

ADHD/Attention Issues

School/Academic Concerns

Other

Please describe the specific concerns and reason for referral: *

Support Requested *

Individual Therapy

Family Therapy

Child/Adolescent Therapy

Diagnostic Evaluation

Other

Additional Notes or Relevant History (Optional)

Consent Form to Release Information (If Applicable)

Please fill out the Record Release Authorization after Submitting this Form

Referral Submitted By (Name):

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Date Today *