Third Party Referral Form
ATTENTION: This form is for community providers making a referral for parent coaching.  If you are a private family wanting support or court-ordered to contact us, you will need to schedule a free 30 minute consultation and complete the private family intake form.  Thank you.

As of 5/1/25, we have a waiting list of about 6-8 weeks.  To help connect coaches and clients faster, please know the client's availability and include it in this form.  We have recently added coaches to our team and are reassessing availability and caseloads, allowing us to address our waitlist faster.  Thank you for your patience!

Before completing this form, please review the two following documents, both of which reflect the current host county contract information: Memorandum of Understanding and Services and Fees. Submitting this referral signifies your agreement to the terms of these documents and that you have a signed Release of Information for your client.  Please email a copy of the ROI to timeoutbehaviorcoaching@gmail.com. 

Thank you for your interest in our services.  It will be our privilege to work with you.
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Email *
Your Name *
Your Title or Role *
County of referring organization *
Department of referring organization *
Phone number of person making referral *
Who will be billed for the service? *
First and Last Name of billable client (child for whom services should be focused) *
Age of billable client (child for whom services should be focused) *
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