Thrive Beyond Therapy Provider Referral
This quick referral form helps us connect with your client within one business day, ensure coaching is a good fit, and get them started. It takes about two minutes to complete.
Provider Information:
Provider Name Completing this request:
*
First Name
Last Name
Provider role/title:
*
Facility or Program:
*
Provider Email:
*
example@example.com
Provider Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Client Information:
Client Name:
*
First Name
Last Name
Client Email:
example@example.com
Client Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Age:
*
Preferred contact method for the patient, if known:
Email
Phone
Text
Client is:
*
Adult
Minor
Parent Name:
First Name
Last Name
Parent Email:
example@example.com
Parent Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Time Zone:
*
Eastern
Central
Mountain
Pacific
Hawaii
Alaska
Primary Reasons for Referral: (Choose all that apply)
*
Difficulty with organization or follow‑through
Transitioning back to school/work
High probability of overwhelm
Executive function challenges (planning, time management, routines)
Support maintaining treatment recommendations
Post‑inpatient stabilization support
Other
Primary Diagnoses or Areas of Focus: (Choose all that apply)
*
Anxiety
Depression
Trauma‑related challenges
ADHD
OCD
Autism / Neurodivergence
Dual diagnosis
Burnout
None
Other
Current Level of Care: (Choose all that apply)
*
Pending or recent inpatient discharge
IOP
Outpatient
Psychiatry/medication management
Case management
None
Other
Is the patient clinically stable and appropriate for coaching?
*
Yes
No
Unsure (We can follow up with you)
What would you like us to know about the patient’s goals or transition needs?
*
2 or 3 sentences are fine, we are just getting a general idea of needs.
Is the patient connected to outpatient providers?
*
Yes
No
Unknown
Is coaching being included on discharge or treatment planning?
*
Yes
No
Unknown
Other
Would you like an update once the patient enrolls?
*
Yes
No
Only if there are concerns
Consent:
*
I confirm that the patient has given permission for this referral and for Raz Thrive Beyond Therapy to contact them.
Other
Submit
Should be Empty: