Counseling Referral Form
Please fill out this form for behavioral health referrals.
***Please note that clients in crisis (suicidal, homicidal, in need of counseling within 48 hours) needs to be evaluated by the crisis team. Please dial 988 as we cannot guarantee a client to be seen in ANY certain amount of time. 
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Email *
If this person is in crisis we have dialed 988 or set up a safety plan until services can be rendered.  *
Patient Name *
Patient email address *
Patient Phone Number *
Patient Insurance *
Referring person: *
Referral email or phone number:  *
Preferred Counselor (if any) *
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