Medical Referral Form
Please fill out the following information for the client or patient you would like to refer to Tranquil Journey Therapy!
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Why is the client seeking therapy services?
*
What days and times would work best for the client's sessions?
*
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Morning Appointments (8AM-11:00AM)
Afternoon Appointments (12:00PM-3:00PM)
Early Evening Appointments (3:00PM - 5:00PM)
Late Evening Appointments (6:00PM - 8:00PM)
Does the client prefer in-person or telehealth sessions?
*
Please Select
In-Person (Pueblo, CO)
Telehealth
Does the client know who they would like to work with?
*
Please Select
Rachel Soto
Beth Martin
Candice Beggs
Kurt Rivera
No Preference
Visit our website at www.tranquiljourneytherapy.org to learn more about our therapists!
Our therapy dog-in-training is usually in the office, bringing extra warmth and comfort—just let us know if the client has any allergies or prefer a dog-free space, and we’ll make sure they are comfortable. 🐾
*
No problems here! Bring on the puppy!
I prefer to have in-person sessions in animal-free space.
I prefer to have sessions by telehealth.
If the appointment times the client selected are not available at this time, would they like to be added to our waitlist?
*
Please Select
Yes
No
I'd like information on other practices that may have the days and times I need
Do you have insurance (including Medicaid/Medicare)?
Yes
No
What Insurance Do You Carry? (type N/A if you do not)
*
What is/are the Insurance ID/Member ID/Group Numbers? (type (N/A if you do not have this)
*
Please Upload an Image of Your Insurance Card (front) *Mandatory for Commercial Insurance - Not for Medicaid/Medicare*
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Cancel
of
Please Upload an Image of Your Insurance Card (back) *Mandatory for Commercial Insurance - Not for Medicaid/Medicare*
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Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: