Therapy Referral Form

Thank you for taking the next step toward your mental health needs. Once you've completed this form, someone from our office will contact you within 48 business hours.

Prospective Client's Fist name

Email (Parent/Guardian's if client is a minor)

Date of Birth

Parent/Guardian First Name (if client is a minor)

Prospective Client's Last name

Phone (Parent/Guardian's if client is a minor)

Gender Identity

Parent/Guardian Last Name (if client is a minor)

Select an Address

Insurance Provider (If Self Pay add “self pay” to field)

Insurance ID: (If Self Pay add “self pay” to field”)

Referred By (If court ordered add "Courts" to field

Reason for seeking therapy:

Thank you for completing the form! We are excited to get you started and will contact you within 48 business hours with further information. If you'd like a 15-minute consultation before making any decisions, feel free to mention it when someone from our office reaches out.