Inner Reins Referral Form

Inner Reins Counseling

Referral Form
Clinical Scope of Practice
Due to scope and capacity limitations, Inner Reins Counseling does not accept referrals for individuals presenting with:
- Severe mental illness
- Current high-risk or unsafe behaviors
- Active substance use
These concerns must be addressed and stabilized through a higher level of care prior to beginning services with this practice.
Date of Referral:

MonthDayYear
Date
Referral Source

Community Connected for KidsDepartment of Children and FamiliesHealthy StartSelf-ReferralOther
Name of Referral Source*

First NameLast Name
Phone Number of Referral Source*
Please enter a valid phone number.
Email of Referral Source*
example@example.com
Please Explain Reason for Referral: *
Services Requested (Check All that Apply):*

Child Parent Psychotherapy (CPP) *DCF involvement not required*Circle of Security Parenting Program (COSP) 8-Week ProgramLoss and Post-Abortion Grief CounselingIndividual Therapy for Mothers (Perinatal & Postpartum)Through the Eyes of the Child (TEC) Co-parenting Intervention. *Not intended for parents involved in active custody disputes or high-conflict situations.*Spiritual/Religious Trauma Support
Client Information and Demographics
Client's Name:*

First NameLast Name
Client's Date of Birth:*

MonthDayYear
Date
Client's Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Phone Number:*
Please enter a valid phone number.
Names of Biological Parents:

First NameLast Name
Contact Number for Biological Parents:
Please enter a valid phone number.
Name of Caregivers or Foster Parents:

First NameLast Name
Contact Number for Caregivers or Foster Parents:
Please enter a valid phone number.
If the child has been sheltered, please outline details regarding the visitation schedule.
DCM Name:

First NameLast Name
DCM Phone Number:
Please enter a valid phone number.
DCM Email:
example@example.com
Insurance Carrier: The following insurances are accepted at this practice.*

AetnaAmbetterCignaFlorida BlueSunshine MedicaidUnited Health/Optum/OxfordNone
Member ID Number: *
Please Add Copy of Insurance Card: (If Available)

Cancelof
Referral Acceptance Notice:

Acceptance of referrals is contingent upon scheduling availability and geographical location. Notification of referral status will be provided within three (3) days of receipt.
Should be Empty:

Inner Reins Counseling

Clinical Scope of PracticeDue to scope and capacity limitations, Inner Reins Counseling does not accept referrals for individuals presenting with:

Client Information and Demographics

Referral Acceptance Notice:

Clinical Scope of Practice
Due to scope and capacity limitations, Inner Reins Counseling does not accept referrals for individuals presenting with: