Happy Place Therapeutic Services Referral From
Name
First Name
Last Name
Email
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Phone Number
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Format: (000) 000-0000.
Preferred Method of Contact
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E-Mail
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Referral Information
Referring Provider / Practice (if applicable)
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Do you have Insurance?
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If insured, please indicate your insurance company and policy number
Upload a copy of your Drivers License, State ID or Military ID and Insurance Card for insurance verification. (Insurance must be verified as active before an appointment is scheduled)
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Please indicate what service(s) you are interested in:
Telehealth Mental Health Therapy
Therapy-Driven Weight Loss Program
Happy Place Reduced Fee Program (not eligible for Therapy Driven Weight Loss)
For Therapy Driven Weight Loss are you interested in:
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Group
Individual
One Time Deep Dive Session
Please include any additional information you would like us to know here. If you have a preferred provider please indicate here.
How did you hear about Happy Place?
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