EmBODY Confidence Counseling Referral Form
Providers: Please complete this form to make a referral to EmBODY Confidence Counseling, LLC. We will reach out to you via your preferred method of contact within 48 business hours.
Email *
Referring Provider's Information
Please complete the following about the referring provider.
Provider's Name and Credentials
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Practice/Facility Name and Address
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Referring Provider's NPI
Provider's Email Address
 *
Provider's Phone Number

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If additional information or communication is needed, what is your preferred method of contact? 
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Client Information
Please complete the following about the client you are referring.
Client's Legal First and Last Name 
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Client's Preferred Name and/or Pronouns
Which state does the client live in?
Client's Date of Birth
 *
MM
/
DD
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YYYY
Client's Phone Number
 *
Client's Email
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Which service is this referral for? 
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If this client is being referred for Eating Disorder, or Disordered Eating Counseling Services, who else is on the interdisciplinary team? (I.e., dietitian, nutritionist, psychiatrist, primary care physician, etc.)
Diagnosis code:
Please list the diagnosis code(s) for the condition/reason for your referral. If there is not yet a diagnosis, please describe the main reason/concern for the referral. 
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What other information is important for me to know?
How did you hear about EmBODY Confidence Counseling?
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Thank you for your referral!
At this time, we will review the referral and reach out to the client directly. If you have any questions or concerns, please email us at jfry@embodyconfidencecounseling.org.
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