Norooz Clinic Foundation Referral Form
Mental Health Services Referral Form

Please email us at info@noroozclinic.com if you have any questions.

Address: 1560 Brookhollow, Suite 214, Santa Ana, CA 92705
Phone Number: (714) 386-9171

Please email us or give us a call after you submit this form.
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Email *
Referring Agency Information
Please fill out your information.
Agency/Department *
Phone Number *
Email Address *
Client Information
Please fill in the client's information in this section.
Client Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Type of Services  *
Required
General reason for service referral (For client: What led you to consider therapy or psychological testing today?)
 *
Email Address *
Phone Number *
Can we text this phone number? *
Availability for Services (please also check either morning or evening at the bottom of this list and select all that apply) *
Required
Where do you prefer your session to take place? *
Language Spoken
Parent/Caregiver Information (if client is a minor)
Name
Relationship with client (mother, father, legal guardian, sister, etc.)
Phone Number
Service Agreement & Authorization to Release Information
The referring party has explained to me the purpose for this referral and I agree to have a copy of this referral emailed or to take a copy of the referral to Norooz Clinic Foundation. I agree to attend any scheduled appointments with the Services.
I authorize the release of information between (referring agency) and Norooz Clinic Foundation for the period this service agreement remains in effect. This information will pertain to the reasons for referral and will be used for assessment and intake of the participant(s) to be served. This referral was explained to me in my primary language.
Please Sign Participant's Name & Date *
Please Sign Referring Person's Name & Date *
A copy of your responses will be emailed to the address you provided.
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