Referral Form

Infinity Growth, A Psychotherapy Practice PLLC

Maren Londahl-Smidt, LCSW, LCAS

919-675-2259 (call, text, voicemail)

Maren@Infinitygrowthpractice.com

8300 Health Park, Suite 201

Raleigh, NC 27615


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Date *
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Time
:
Patient Name (First and Last) *
Guardian name (if client is a minor) *
Date of Birth *
Is client 12 or older? *
Email *
Phone Number (if minor please include guardian contact information) *
Preferred Contact Method *
Required
Insurance 
*I am out of network with all insurances, outside of Aetna.  I do provide a superbill and I'm happy to assist with out of network claims
 *
In person or telehealth? *
Requested service *
Is the client aware they are being referred? *
Client Mental Health Diagnosis *
Presenting Issues for Therapy. Please tell us what is bringing you to seek therapy services at this time: *
Presenting Symptoms and/or concerns that we treat.  Please note I am not a crisis provider and am unable to accept  the following: 11 or under, active suicidal ideation, homicidal ideation, hallucinations, bipolar, schizophrenia, personality disorders, developmental disabilities, and behavioral issues. *
Column 1
Anxiety
Social Anxiety
Panic Attacks
Depression (no active SI)
Attachment/Inner Child
ADHD
Self Esteem/Self Worth
Emotional Trauma
Life Transitions
Grief
Boundaries
Medical stressors/Chronic Illness
Sleep Difficulties
Sports Performance/Anxiety
Addiction
Parenting support/healthy attachment
Emotional awareness
Addiction support for loved ones
Relationship anxiety
Adjustment(s)
Current medications *
Referring Provider *
Person making the referral/contact info *
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