Referral Form
Please note that we cannot provide a timeframe on assignment of referrals given the individualized nature of each person and each family's needs.  Please note, we do not accept TriCare and Medicare Insurance. At this time, in person and afternoon/evening hours are extremely limited.
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Email *
Date of Referral *
MM
/
DD
/
YYYY
Referral made by: *
Client  *
Preferred/Chosen Name *
Parent/Guardian Name
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Pronouns 
Client Address *
Parent/Guardian Address (if different from client)
Phone Number *
May we leave voice mail? *
May we send text messages (for scheduling purposes)? *
What type of communication do you prefer or use most frequently? (Please check all that apply) *
Required
Reason for Referral *
What would you prefer?  *
If you are interested in school based counseling, what district and school does your child attend? (please note, school based may not be available depending on district) *
What availability do you have for therapy? *
Required
Insurance Plan Name & Policy Number *
Is there a secondary insurance plan?
Clear selection
If yes, please identify below
What do you need support with? *
Required
Services Interested In *
Required
Submit
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