Client Referral Form

Who is this request for services for?*

Adult (21 years or older)Child (under 21 years of age)
Please list full name of Person completing this form
Client Name*

First NameLast Name
Please list the full name of the parent or guardian who is responsible for authorizing treatment*
Please list relationship to client
Please list relationship to client*
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Primary Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date of Birth
Sex*

FemaleMale
Is the client Active Duty Military, a reservist, or a First Responder?

YesNo
Please List the Name of Your Insurance Company
Please Provide Your Insurance ID number
Please Provide Your Insurance Group Number
Is the client currently experiencing thoughts of suicide or suicidal ideation?.*

YesNo
Please ensure immediate safety by calling the Suicide & Crisis Lifeline at 988 or going to the nearest Emergency Room for help!
Does the client have any of the following concerns? (Check all that apply)

Anxious/worriedDepressed/unhappyEating disorder/body image concernsHyperactive/inattentiveShy/withdrawnLow self-esteemAggressive behaviorsStealingDestruction of propertyAngerDishonestyNone
Does the client have any of the following concerns with school? (Check all that apply):

Homework not turned in/not completedLow test/assignment gradesPoor classroom performanceSleeping in class/always tiredSudden change in gradesFrequently tardy or absentNew studentPersonal hygieneNone
Does the client have any of the following concerns with relationships? (Check all that apply):

BullyingDifficulty making friendsPoor social skillsProblems w/friendsBoy/girlfriend issuesNone
Does the client have any of the following concerns at home? (Check all that apply):

Fighting w/family membersIllness/death in the familyParents divorced/separatedSuspected abuseParent RequestNone
List any other information that you would like us to be aware of regarding the client and/or yourself?
How did you hear about us ?*

InstagramFacebookEmailGoogleTelevisionRadioTikTokOther
If other , Please list here
Should be Empty: