Referral for Psychotherapy Services

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Email *

Person / Organization Making Referral

In this section, tell us WHO IS MAKING THE REFERRAL and how we can contact you if needed.

First Name *

Last Name *

Title / Position

Name of organization

Phone number

How did you hear about us?

Note About Confidentiality:

In order to preserve confidentiality, we cannot guarantee that we will be able to inform you whether your referral followed through. However, in some cases, it may be helpful to collaborate on treatment. The client MUST give consent and sign a release of information before we can share any information with you. If you do not hear back, you may assume the person either did not follow through or the person did not give consent to notify you that an appointment was made.

If the client gives consent, would you like to be notified whether your referral followed through with making an appointment?

Yes

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