Referral Questionnaire

We are glad to be able to offer referrals to some of the best providers in the Middle Tennessee area. We have access to many trusted practitioners across a variety of specialties.

In order to help us recommend the most suitable referral(s), please answer the following questions. The more insight you are able to offer about your preferences, the more specific we can be in our recommendations.

Please allow 5-7 business days for us to review and offer next steps. Thank you!

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Email *
First Name *
Last Name *
Mobile Phone # *
GENDER - Do you prefer a male or female counselor? (Select any that apply.) *
Required
Are you interested in individual or couples work? *
LOCATION - Do you prefer a particular part of town? (Select any that apply.) *
Required
MODALITY - Are you seeking a certain approach or modality? (Select all that apply.) *
Required
SPECIALTY - Are you seeking any particular speciality? (Select all that apply.) *
Required
FAITH / SPIRITUALITY - What importance does faith & spirituality hold for you as it relates to counseling? (Choose the statement that best describes you.) *
GOALS - Briefly share what you would like to work on in therapy. (This will help us determine which of our referrals might be the best fit for your specific needs.) *
COST - Are you able to pay the conventional hourly rate for counseling / therapy ($100-$200) or do you need an option for a sliding scale (reduced fee)? *
INSURANCE 
We have very few providers in our network who file insurance. However, many of them can issue statements for insurance reimbursement. If you need your provider to file insurance, we recommend you reach out to your insurance company for a list of providers that meet your criteria (location, telehealth options, etc.). 
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