Breaking Free Services Provider Referral Form

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This form is for professional use only. Please complete the information below to refer a client to Breaking Free Services. Once completed, you may email any additional paperwork or documentation to clientcare@breakingfreeservices.com.

Type of Referring Provider *

Lawyer

Doctor

Guardian ad Litem

School Counselor

Inpatient or intensive Outpatient Staff/Center

Substance Use Treatment Programs

College/University staff

Community Resources (Domestic Violence/Homeless Shelter, Faith Leaders, VA Organizations)

Referring Provider Name *

Provider Phone Number *

Provider Email Address *

Client's Full Name *

Client's Date of Birth *

YYYY

Parent/Guardian Name (if applicable) *

Client or Guardian's Phone Number *

Client or Guardian's Email Address *

Presenting Concerns/Reason for Referral *

Services Requested *

Group Therapy

Individual Therapy

Family Therapy

Couples Therapy

Required

Has the client previously received mental health treatment *

Yes

Submit

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