Referral Form

Confidential Referral Form
All information provided will remain confidential and used solely for the purpose of assessing service needs.

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Urioste Therapy, LLC Referral Form
Referral Information: 
Date of Referral *
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DD
/
YYYY
Referral Source (Please Select One) *
Required
Information of Person/Organization Making Referral
Phone:  *
Email: *
Address:  *
Relationship to Client: *
Client Information: 
Client Name:  *
Date of Birth:  *
Age:  *
Gender/Pronouns *
Parent/Guardian Name if Minor:  *
Phone:  *
Email  *
Address:  *
Preferred Contact Method:  *
Required
Reason for Referral: *
Services Requested:  *
Required
Additional Information:
Has the client received counseling or therapy before?

 *
Is the client currently taking any medications related to mental health?

 *

Safety and Crisis Information:

Does the client currently experience thoughts or behaviors of self-harm or suicide?

 *

If yes, please ensure the client receives or has access to immediate safety resources, including but not limited to:

Safety Resources:

988 Suicide & Crisis Lifeline: Call or text 988 (24/7 free and confidential support) Crisis Text Line: Text HOME to 741741 Local Emergency Services: Call 911 or go to the nearest emergency department If in New Mexico (example): Call NM Crisis and Access Line – 1-855-NMCRISIS (1-855-662-7474) 
I have provided the client (or guardian) with the above crisis and safety resources.
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Referral Follow Up
Would you like to be contacted for confirmation of this referral?

 *
Best way to reach you: (Reminder: If you are referring from an agency or school setting, a signed Release of Information (ROI) will be required before any client information can be shared.)   *

Urioste Therapy, LLC

Mailing Address: P.O Box 1675 Las Vegas, NM 87701

Phone: 505-429-3385

Email: samantha@uriostetherapy.com

Website: www.uriostetherapy.com

Note: At times, Urioste Therapy, LLC may have a waiting list for services. If immediate openings are unavailable, I will inform the referring party and can either place the client on a waiting list or provide alternative referral options and community resources.  
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