SMCCC Clinician Referral Form

Client Referral Form

Please use this form to submit basic contact information for a prospective client you would like to refer to Shezetta Morris Coaching, Consulting, and Counseling Inc. (SMCCC). A member of our team will contact the individual directly to discuss available services and next steps. Please do not include any clinical details, diagnoses, treatment information, or other Protected Health Information (PHI) on this form. This referral form is intended for contact information only.
Referring Professional/Organization
Referring Professional's Full Name

First NameLast Name
Referring Professional's Credentials
Professional's Email Address
example@example.com
Professional's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Organization or Practice Name
Date of Referral

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Prospective Client
Reason for Referral
Prospective Client Contact Information
Client's Full Name

First NameLast Name
Preferred Name
Client's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client's Email Address
example@example.com
City/State

Street Address

Street Address Line 2

CityState / Province
Best Days/Times to Contact
Preferred Contact Method
Permission to Leave Voicemail
Additional Notes or Comments
Service Interest/Contact Permission
Service Interest
Contact Permission
Privacy and Secure Intake Instructions
- Do not include diagnoses, symptoms, treatment history, medication information, safety or risk details, insurance member numbers, identification documents, or clinical records on this form.
- For referrals involving protected health information or clinical records, coordinate a secure method of transmission with SMCCC.
- Do not send sensitive health information through unsecured email.
- The prospective client may initiate intake directly through the secure portal: smccc.clientsecure.me.
- For psychotherapy, the prospective client must be physically located in Florida at the time of service.
Type a question
Referral Follow-Up

Secure Intake Portal: smccc.clientportal.me
Practice Website: www.shezettamorris.com
Submission of this form does not guarantee appointment availability, acceptance into services, or insurance coverage.
Should be Empty:

Client Referral Form

Referring Professional/Organization

Prospective Client Contact Information

Service Interest/Contact Permission

Privacy and Secure Intake Instructions

Referral Follow-Up