For Professionals: Make a Referral
If you are a care provider and would like Relate to reach out to someone you believe would benefit from our services, please complete the form below.
Person submitting the referral:
*
First Name
Last Name
Referring agency:
*
Email for the above agency:
*
example@example.com
Phone number for the above agency:
*
Please enter a valid phone number.
Person you are referring for services at Relate Counseling Center:
*
First Name
Last Name
Date of birth:
*
If the referred person is a minor, please note parent/guardian name and relationship:
Email:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Please note any provider preferences, treatment methods, or additional information that would best assist us in serving the above person:
What is the availability of the referred person for services?
8am-Noon (immediate availability for most ages)
12pm-3pm (immediate availability for most ages)
3pm-5pm (likely wait time of 8+ weeks)
By typing my name below, I am confirming that I have alerted the referred person above (or their parent/guardian) of this referral and they give permission for Relate Counseling Center to reach out to them about services:
*
Please verify that you are human
*
Submit
Should be Empty: