Professional to Professional Client Referral Form

Thank you in advance for your kind referral!  Please complete this worksheet on our HIPAA secure platform. The administrative staff will be notified that an entry has been made and will contact the client you have referred. Alternately, you can also email referral information to intake@legacycounselingservices.com or                          
fax it to (888) 371-9410. To review the services we offer, please visit our website: https://legacycounselingservices.com/

Please note that due to high client volume, it may take our administrative team 3-5 days to contact you and/or the person you are referring to us. We appreciate your patience and your trust in us.
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Email *
Client / Patient first and last name *
Client / Patient age *
Client / Patient phone number *
Client / Patient email address *
Are you referring for mental health treatment, life coaching, or health and wellness coaching? *
What is the primary reason for the referral? *
Client / Patient insurance, if any *
Is the client / patient aware, and open, to this consult for mental health counseling and/or coaching? *
Name of person making the referral *
Practice, or business name, of the referring agency. *
Phone number of referring person. *
Is this a HIPAA / secure phone number that we can leave a voicemail on regarding the referral? *
Email address of the referring person. *
Is this a HIPAA-complaint / secure email address that we can use to communicate back with you regarding the referral? *
Fax number of referring person. *
Is this a HIPAA-complaint / secure fax number that we can use to communicate back with you regarding the referral? *
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