Aurora Counseling Center

Counseling Referral Form

Thank you for your referral! We appreciate your trust in Aurora Counseling Center to support those in need. Please complete the form below to help us guide them toward healing and growth.
Referring Party Information:
Name

First NameLast Name
Organization (if applicable):
Phone Number
Please enter a valid phone number.
Email
example@example.com
Client Information:
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Reason for Referral:
Type a question
Additional Information:
Previous Counseling or Therapy:

YESNO
If yes, please provide details:
Preferred Appointment Details:

MondayTuesdayWednesdayThursdayFridaySaturday
Preferred Time:

MorningAfternoon
Referring Party Signature:

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Submission Instructions:
At Aurora Counseling Center, your privacy is our priority. Please complete the form without including sensitive information (e.g., Social Security numbers). We follow HIPAA guidelines to keep your information secure and will follow up via your provided contact details.
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Counseling Referral Form