Getting in Touch: New Client Referral Form

For new client referrals, please complete the form as thoroughly as you can. We strive to protect all client information and confidentiality. The completed form is encrypted and sent to our administration team for review. Please be aware that we have a wait list at this time for all new referrals.

Referred By

First Name

Last Name

Client Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Gender

Parent/Guardian Name

If applicable

First Name

Last Name

Phone

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

State ward?

Yes

No

Not Applicable

If yes, please list the following:

Insurance Provider:

Insurance ID #:

Insured's Name:

Insured's Employer:

Insured's Date of Birth:

Diagnosis if known:

Presenting Issues:

Any other pertinent medical information

Client currently has a Psychiatrist/APRN

Yes

No

If yes, Psychiatrist/APRN name:

Client needs appointment scheduled with a Psychiatrist/APRN ASAP

Yes

No

Preferred Clinician

Business Hours

We are open Monday through Thursday from 8:00am - 5:00pm.
Evening and Friday appointments may be scheduled at the clinician’s discretion and availability.

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