Referral Form

I will contact you as soon as possible. If you are in crisis, please call your county’s mental health crisis line or 9-1-1 in the event of an emergency.

Name of Person Seeking Counseling

First Name

Last Name

Who are you referring?

Referral's Pronouns (she, he, they, them, etc.)

If you are not referring yourself, is the person aware that you are referring them for counseling?

Yes

Unsure

Referral Source

If you are not the person seeking counseling, please provide your name, your phone number, your email address, and how you are related to the referral. If you are referring youself, please indicate how you found me (ex. social media, friend, referral from a professional etc.).

Phone

(###)

###

####

Email Address

Type of Therapy Requesting

Please indicate which type of therapy you are requesting.

Subject

Type in your subject line here (ex. Counseling Referral)

Message

Leave a Voicemail?

Is it okay for me to leave a voicemail?

Yes, please leave a detailed voicemail

Yes, but please keep it general

No, please follow-up with an email if no answer

Best Time to Connect?

8am-5pm

5pm-9pm

Anytime