Direct referral to Brave Mind Therapy

Client's full name

Email address

Phone number

Briefly (max. 3 sentences) explain the reason for this referral

Client's preferred date for an appointment

We are currently accepting appointments on Thursdays from 12PM-6PM

Please confirm the following eligibility criteria:

Client is between the ages of 14-25 OR is a parent.

Client is not looking to to process past events (ex. trauma).

Client is aware of the referral and interested in goal-oriented, future-focused therapy.

Client has the means to pay for therapy (session rates are $160/50 mins, not covered by MSP).

I have read and understood the instructions above.

Referring provider name

Email address

Phone number

Organization name

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