Counseling Referral Form
Client/Patient's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Last 4 of SSN
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How will this client/patient pay for services? (if known)
Insurance (We are paneled with UHC, Aetna, CIgna, Oxford, Oscar, FL Blue)
Self Pay
Self Pay with Student Intern ($79 for 4-8 sessions a month)
Office of the Attorney General/State of Florida
Church (please specify)
Notes:
Is Individual aware of this Referral?
Yes
No
Program Referring to:
Every Girl Living (Women's Issues, ages 13-80+)
The Marriage Foundry (Marriage and Family Counseling, including children)
Salvo (12 Week Pornography Addiction Program)
Type of Services Needed
Individual Adult Counseling
Marriage/Couple's Counseling
Child/Adolescent Counseling
Individual Yoga
Personal Training
Life or Wellness Coaching
Salvo (Pornography Addiction Program)
Soul Bourn Women's Empowerment Group
Yoga Classes
Individual Gender
Male
Female
Other
Individual Primary Language
English
Spanish
Other
Reason for Referral
Select all applicable challenges below for the Individual referred (check all that apply)
Anger
Anxiety
Depression
Grief
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Nutritional
Phobia/s
School behavior
Self Harm
Separation Issues
Social Skills
Substance Use
Trauma
Whole Health/Wellness
Youth to Young Adult Transition
Relationship Issues
Career
Men's Issues
Pornography Addictions
Divorce
Domestic Abuse
Mood Disorder
Bipolar Disorder
Other
Other, please specify
Referred by:
Name
First Name
Last Name
Company/Organization
Email
example@example.com
Phone Number
Please enter a valid phone number.
Submit
Should be Empty: