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FAQ'S

Therapy Referral Form

Client Full Name*

Date of Birth*

Month

Day

Year

Gender Identity

Ethnicity (optional)

SSN / MA # (Medicaid ID)*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Parent/Guardian Name (if minor):

Phone Number*

Email*

School Name (If applicable)

Current Grade

Highest Level of Education Completed

Receives Special Education Services (IEP/504)?

Yes

No

Unknown

Referral Source Information

Referring Individual/Organization

Your Name & Title

Relationship to Client

Phone Number

Email

Date of Referral

Month

Day

Year

Reason for Referral

Please select all that apply*

Anxiety / Panic

Depression / Mood Changes

Trauma / PTSD

Grief and Loss

Family Conflict

Behavioral Concerns

ADHD

School-Related Issues

Autism Spectrum

Social Skills / Peer Relations

Adjustment Difficulties

Parenting Support

Other

Brief Description of Concerns

Services Requested

Please select all that apply*

Individual Therapy

Family Therapy

Parent Support

Telehealth Services

Diagnostic Evaluation (if available)

Other

Brief Description of Concerns

Additional Notes or Special Considerations

(e.g., safety concerns, communication needs, legal involvement):

Consent & Confidentiality

By submitting this referral, I affirm that I have obtained the necessary permissions to share the above information in accordance with HIPAA and applicable privacy laws.

Ensuring these fields are completed will help facilitate timely and appropriate intake and service coordination.

Together, we can build a healthier, more supported community.

Get Started Today

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