Referral Documents
Access and download essential forms for referrals, consent, and treatment planning
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📋 Referral Forms
General Client Referral Form
Comprehensive referral form for new clients seeking mental health services. This form collects essential information about the client, their needs, and referring provider details to ensure appropriate service matching and care coordination.
About the General Client Referral
To help our team match you with the right services quickly and coordinate care with your insurer, the referral form gathers:
- Basic details: referral date/source, client name, DOB/age, address, phone(s), and your preference about identifying our clinic by name when we call.
- Demographics (self-identified): gender identity, race, ethnicity, birth sex.
- Reason for referral & setting: outreach or in-office; telehealth; home/school-based; new intake or transfer; psychological testing.
- Presenting concerns & service type: individual, couples, or family therapy; psychological testing; psychiatric evaluation.
- Clinical info (if available): DSM-5 diagnosis and ICD-10-CM code, current/prior treatment and providers, current/past meds and prescriber, therapist preference (male/female), schedule availability.
- Insurance & authorization: insurer, plan/group, member ID, policyholder info, benefits (deductible/copay/visit limits), and any pre-auth numbers/dates.
If you don’t have some clinical items (like diagnosis or codes), leave them blank—your provider can complete them during intake.
Therapeutic Mentoring (TM) Referral Form
Specialized referral form for Therapeutic Mentoring services, designed to support children and adolescents with behavioral health challenges. This service provides one-on-one mentoring to help youth develop coping skills and achieve treatment goals.
In-Home Therapy (IHT) Referral Form
Referral form for In-Home Therapy services, providing family-centered therapeutic interventions in the comfort of the client's home. This service supports families in creating sustainable positive changes within their natural environment.
📋 Consent Forms
Telehealth Informed Consent Form
Comprehensive informed consent form for telehealth services, outlining the nature of remote therapy, privacy considerations, technical requirements, and client rights. Essential for all clients participating in virtual therapy sessions.
Questions About Our Forms?
If you have questions about which form to use or need assistance with the referral process, our team is here to help.