Request for Services

Request for Services

This form is to submit a referral to HWS Best Health Counseling for our various service lines including counseling/psychotherapy, case management and medication management. If HWS is able to accept, the client or guardian will be contacted to complete intake paperwork.If HWS is able to accept, the client or guardian will be contacted to complete intake paperwork.

Parent/Guardian Contact Information
Parent/Guardian's Name*

First NameLast Name
Parent/Guardian's Phone Number*
Please enter a valid phone number.
Parent/Guardian's Email Address*
Providing this will reduce referral wait times
Check Here if Parent/Guardian's Address is the Same as the Clients*

Same Address
Parent/Guardian's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Referring Organization Information
Additional Notes / Things We Should Be Aware of
Name of Referring Individual*

First NameLast Name
Title of Referring Individual*
ie. Social Worker, Principal, Primary Care Doctor, etc.
Phone Number of Referring Individual*
Please enter a valid phone number.
Email Address of Referring Individual*
example@example.com
Should be Empty: