Date

MM

DD

YYYY

Person filling out form *

First Name

Last Name

Phone *

(###)

###

####

Client's Name *

First Name

Last Name

Client's Phone *

(###)

###

####

Former Client? *

Yes

No

Sex *

Female

Male

Other

Prefer not to say

Type of Counseling *

Please select all that apply. If you are seeking individual counseling for more than one person, please fill out a separate referral for EACH person.

Individual

Family

Marriage

Play Therapy

Are you comfortable seeing a therapist who may be of a different gender/ethnicity than you? *

If not, please specify in the next box

Yes

No

Would you prefer In Person or Telehealth services? *

In Person

Telehealth

No preference

Payment *

I can self-pay

I need help with payments

Insurance *(see below)

Availability (1/2) *

Please select the days of the week that would work best for you for scheduling appointments.

Monday

Tuesday

Wednesday

Thursday

Friday

I can do any day of the week.

Availability (2/2) *

Please select the times of day that would work best for you for scheduling appointments.

Mornings (8am-12pm)

Afternoon (1pm-4pm)

Evening (5pm-8pm)

Any time of day works for me.