This referral form collects information from you to identify your needs and connect you with a counselor. By filling out this document, you are consenting to having your information sent to clinicians within Rocktown Counseling for follow-up. Your information will not be sent to outside agencies or used for anything other than to contact you and match you with a clinician. The referral process could take from a few days to one or two weeks depending on clinician availability. Please feel free to follow up about your referral by emailing intake@rocktowncounseling.com or using the contact form on our website.

For any questions, email intake@rocktown.counseling.com.