Support Referral Form

Your Name

First NameLast Name
Best contact number if we have questions.
Do we have permission to disclose you as the referral source to the individual?
Referral Details

Please fill out the following information in detail. Thank you!
Name

First NameLast Name
What is your relationship to the person you are referring?
What resources or services are you requesting?

Other
If you answered other above, please explain.
Please share the reason for your referral providing as many details as possible.
Do we have permission to share your reason for the referral with the individual? Please inform the individual that you have placed a referral for them.
Do you feel the individual is a harm to themselves or others at the time of this referral? If yes, please explain in detail. Depending on the circumstances, we all have a duty to report when someone is in danger. Please share if you have reported the danger to the police, if you answered yes?
Date of Birth

DayMonthYear
Date
Approx Age
Gender
Pronouns
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the individual you are referring, living in a safe environment, that you know of? If not, please explain.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Primary language spoken
Do you identify as Culturally and Liguistically Diverse?
Please note any cultural needs.
Do you know if the individual has health insurance benefits?
Is the individual currently seeing a therapist?
Please note any medical conditions, we should be aware of.
Contacting the Participant
Preferred contact method?
Preferred first contact

Other
Please note contact name and details for first contact, if other than individual. For example, mother of a minor.
Primary contact person
Primary contact relationship to the participant
Primary contact phone number
Please enter a valid phone number.Format: (000) 000-0000.
Primary contact email address
example@example.com
Please list other support services in place for the participant, if known.
Referral submitted by:
Name

First NameLast Name
Signature
Mental Health Support Referral Form

If you or someone you know is in need of a mental health therapist or support please fill out the following information providing as much details as possible. All referrals are confidential.
As of right now, do you feel safe? Is the person safe?
Preferences for therapist? Check all that apply.
What is the best time to contact you and how?
Thank you for your referral.

We will may contact you for more information via email or phone. We honor you for reaching out for support. It takes a strong person to do so! We will be in touch ASAP. If you are experiencing an emergency call 911 or go to your local police station, hospital or shelter.
Should be Empty:

Referral Details

Contacting the Participant

Referral submitted by:

Mental Health Support Referral Form

Thank you for your referral.