Clinician – Direct Referral [MHC]

Direct Referral - Mental Health Counseling

If you have a direct referral, please work with the Prospect to choose a time/location first, then complete the form. This applies to: Referrals from providers from another practice, a Prospect that contacts you directly, via email, phone, healthprofs.com, etc., or a former client resuming treatment.

Choose Direct Referral as the Early Inquiry Method and Mental Health Counseling as the service.

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Therapist Name

Early Inquiry Method*

Choose which service this is for*

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First Name

Last Name

Preferred Name or Nickname

Email*

Date of Birth*

Current Age

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If appointment date/time/location is already chosen, please include that information here:

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