Referral Assistance Program

Thumbs Up High 5K, a Minnesota nonprofit corporation, (the “Organization”), offers to those the Organization serves as part of its charitable purposes as a 501(c)(3) tax exempt organization, participation in a free, electronic referral program (the “Referral Program”) for referral of a participant to receive five (5) free sessions of counseling or therapy provided by a licensed counseling agency in the area that has agreed to receive such referrals from the Organization.

By offering the Referral Program, the Organization is not in any way, through the Referral Program or otherwise, offering or providing any counseling or therapy services, or any intake or processing for any counseling or therapy services, or any emergency or crisis counseling.

In the event the Participant cancels less than 24 hours prior to the Participant’s counseling appointment with the Referral Agency, or does not show up for the appointment, this Agreement will immediately terminate, and the Organization shall have no further obligations under this Agreement.

Age*

I am under 18I am 18 or older

Name*

First NameLast Name

Parent/Guardian (if applicable)

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Select a Facility*

Bridging Hope Counseling - Rogers, Buffalo & Lino LakesCentral Minnesota Mental Health Center - Buffalo, Elk River, Monticello, St. Cloud, Waite ParkHealing Moments Counseling - Monticello, Byron & Sauk RapidsLee Carlson Center for Mental Health & Wellbeing - Fridley, Brooklyn Center, St. Louis Park & Coon RapidsNorthwest Family Counseling - St. MichaelParasol Wellness Collaborative - Otsego, Rogers & Maple GroveThe Center for Hope & Healing - Elk RiverTrilogy Counseling - Elk River, Princeton & St. Francis

Please read the Referral Request Agreement

This is an Electronic “Click” Agreement. The Parties understand and agree to entering into this Agreement by electronic means, and that this is an electronic agreement to which the Participant agrees to be bound by clicking the box marked “I Agree.” The Participant further acknowledges and agrees that this Agreement, in its entirety, has been made available to the Participant for review, and that the Participant has been provided ample opportunity to review this Agreement before signing it. The Participant also acknowledges that it has received (or will receive) from the Organization an email copy of this Agreement signed by both Parties.

Client Signature*

Clear

Parent/Guardian Signature (if applicable)

Clear

Date Signed*

Date