**Please fill in all fields. If one is Not Applicable please type N/A**

From:

My Phone: (xxx)-xxx-xxxx

My Fax: (xxx)-xxx-xxxx

Relationship to Person Being Referred:

Date: mm/dd/yyyy

Name:  (Person Being Referred)

Email:

Street Address:

Daytime Phone: (xxx)-xxx-xxxx

Evening Phone: (xxx)-xxx-xxxx

Date of Birth: mm/dd/yyyy

Age:

Gender: Male Female

Social Security Number: xxx-xx-xxxx

Parent/Guardian (if applicable): Parent Guardian

Primary Health Insurance and ID #:

Description of Presenting Problem:
(500 character max)

Individual Counseling
Couples Counseling
Family Counseling
Psychiatric Evaluation
Medication Management
Drug and Alcohol Counseling
School Based Counseling
Specialized Services

What number should we call? (xxx)-xxx-xxxx