Screener YNC Referral Form

YNCC Client Referral Form

Begin your referral to Your Next Chapter Counseling. We’ll start with a brief safety check, then collect your information to help match you with the right clinician. All information is confidential.
Brief Safety Assessment
Name of person completing this referral?

First NameLast Name
Your phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Your email:
example@example.com
Do you (or client) have thoughts of harming yourself or others?
If you are unable to keep yourself or others safe, please call 911, go to your nearest emergency room, or contact RHA Mobile Crisis at (888) 573-1006 immediately.
Do you (or client) have PLANS to hurt yourself or someone else?
Should be Empty:

YNCC Client Referral Form