Forms

If you are a referring professional, click the form below to fill out our referral form.

Referral Form

Potential Client Name

First Name

Last Name

Responsible Party (if applicable)

First Name

Last Name

Client's Phone Number

(###)

###

####

Client's Full Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client's Date of Birth

MM

DD

YYYY

Insurance Type & Policy Number

Referring Agency/Person

Referring Party's Email

Referring Party's Phone Number

(###)

###

####

Reason for Referral

Describe reason for referral and presenting issues

If you are a current client and need a printable release of information form, please use the link below.

Release of Information

Note: New client forms are sent directly to the client electronically after completing the video consultation with one of our therapists.

For any other issues or questions, please contact our office at (980)533-0856 ext. 1