Clinical Client Referral Form V2024

Client Referral Form

Frances Bunzl Clinical Services and Horwitz-Zusman Child & Family Center
Are you requesting services for yourself or someone else?*

SelfChildSomeone else
Please note: If you are not the parent, legal guardian, or power of attorney for the client seeking services, kindly note that the client must personally submit a request for services. Please ensure that the client returns to this form, emails us at therapy@jfcsatl.org, or contacts our Clinical Referral Line at 770-677-9474.
We appreciate your cooperation in this matter and look forward to assisting the client on their journey to well-being.
What is your relationship to the client?*

ParentGuardianship/Power of Attorney of minorGuardianship/Power of Attorney of adultSpouseCaregiverOther
Person completing this form, if other then the client*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Hillel- Services for College/Grad Students (Only)
How Do You Practice Your Judaism?

Very active – Religiously and culturallyActive – I attend services on a regular basisNo Very active – I go to services on important holidayCulturally Jewish – I don’t practice religiously but I have a strong Jewish identityI am not Jewish

Availability and preferences
What days and times are you generally available for services? (Please provide multiple options if possible.)*
Do you prefer in-person therapy or online/teletherapy sessions?*

In-personOnline/TeletherapyHome Visits (Older Adults Only)Other
Do you prefer in-person therapy or online/teletherapy sessions?

In-personOnline/TeletherapyHome VisitsNo preference
Do you have any preferences related to which clinician you would like to see?*
Review Clinician Bios here: https://jfcsatl.org/services/clinical-services/our-therapists
Additional information
Is there any other information you would like to share that you believe would be helpful for us to know before scheduling an initial consultation?

Client Referral Form