Clinical Referral Form

We welcome referrals from physicians, psychiatrists, nurse practitioners, therapists, school professionals, attorneys, coaches, and other trusted professionals. This form is intended to help us determine whether an individual working with you may be a good fit for our services. This secure form is the first step in referring an individual to our practice. The information submitted through this form does not establish a therapeutic relationship or serve as a clinical assessment, but is transmitted securely and privately. This form helps us understand the referral, the individual's needs, scheduling preferences, and potential fit for our services. If appropriate, and per your recommendation, the individual may choose to contact us directly to explore care. We currently provide remote, private-pay services to individuals located in California, Kansas, and Missouri. Superbills are available for those who wish to seek possible out-of-network reimbursement through their insurance plan. Referrals are reviewed based on clinical appropriateness, availability and overall fit. If an appropriate opening becomes available, we will follow up with you regarding next steps.

First Name

Last Name

Please list your professional credentials

LPCC, LPC, ATR-BC, LMHC, LCSW, PsyD, MD, PMHNP, Attorney, Coach, etc

Organization/Practice Name

Email Address

Phone Number

Preferred Contact Method

Email Phone

Client's First Name

(Optional)

Client's Last Name

(Optional)

Client's State of Residence

Has the individual been informed of this referral?

Yes No Unsure

Why do you believe this individual may be a strong fit for us?

Highly personalized care, private-pay option, current provider at capacity, specialty, etc.

What days generally work best for this individual? Check all that apply

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

What times generally work best for this individual? Check all that apply

Mornings

Afternoons

Evenings

When is the individual hoping to begin/resume care?

ASAP Within a few weeks Within one to three months Flexible Unsure

Is there anything else that would help us determine fit?

Professional Acknowledgment

I confirm that I have permission to share the information submitted through this referral.

I understand that submission of this referral does not guarantee acceptance into services.

How did you hear about us?

Your information will be encrypted.