Fortitude Counseling Associates, PLLC - Request for Services/Referral Form

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"Promoting Positive Change Through Self-Empowerment"

Thank you for choosing Fortitude Counseling Associates.com

Please visit our website at fortitudecounselingassociates.com for more information on our services, rates, and agency information. Complete this Request for Services Form and submit if you are ready to request services for yourself or someone else.

Contact us at FCA@fortitudecounselingassociates.com if you have any questions or concerns.

Current Therapist Providing Trauma Focused Cognitive Behavioral Therapy
Shawn Jones, MA, LCMHC
Charessa McIntosh, MSW, LSCW

Email *

Referral Source Information

This can be someone making a referral for someone else or an adult that needs services themselves.

Date of Referral *

YYYY

Are you making this referral for yourself or someone else? *

Self - I am making this referral for myself. (Click on "Next" at the bottom of this page to go to Client Information.)

Someone Else - I am making this referral for someone else.

Name of Person Making Referral:

Your relationship to the person being referred:

Parent

Social Worker

Therapist/ Psychiatrist

Primary Doctor

Other:

Clear selection

Referrers Phone Number:

Name of Referring Agency or Organization (If Applicable):

Referring Agency NPI (Medicaid Providers Only):

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