Referral Form

Referral Source (Agency/Organization)
Referral Source Name*

First NameLast Name
Referral Source Email*
example@example.com
Referral Source Phone*

Area CodePhone Number
Relationship to Client
Does the client know you are making this referral?*

YesNo
Client Full Name*

First NameLast Name
Peferred Name
Client Phone Number*

Area CodePhone Number
Client Email
example@example.com
Cllient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pronouns
Client Date of Birth*

MonthDayYear
Date
Client Type*

AdultMinor
Best Contact Method*

CallEmail
Insurance Type
Upload proof of insurance.

Upload File

Cancelof
Service(s) Requested

Individual CounselingFamily CounselingParenting / Co-parentingOther
Are services court-ordered?

YesNo
Allowable treatment setting for court-ordered clients:

In-PersonVirtual (via HIPAA-compliant video platform)
Court Order Upload (PDF/JPG)

Upload File

Cancelof
Required Reporting Frequency
Is the client in:

DOJ custodyParent custody (minor)Legal guardian custody (minor)Foster care placementDHS / Child Welfare custodySelf-consenting adult (18+)DHS-involved family (not in custody)Other
Cultural or Accessibility Needs / Additional Information
Greater Changes provides counseling and supportive services for court-involved clients; however, our clinicians do not attend court hearings, depositions, or testify in legal proceedings. We offer therapeutic services, progress summaries, and required treatment updates as outlined in the court order or by the referring agency, but we do not provide evaluative statements, custody recommendations, or forensic reports. Submission of this referral indicates your understanding that our role is strictly therapeutic, and that all documentation will reflect the client’s clinical progress without interpretation or advocacy for any legal outcome.
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