Request for Referrals

This secure form collects the information we need to learn more about you as a clinician so we can determine whether you’re a good fit for any clients we are unable to see at this time. We seek clinicians who meet our standards, and this form allows you to share your credentials, clinical focus, and current availability so we can place clients according to training, clinical experience, scope and ethics.

First Name

Last Name

Email Address

Phone Number

Zip Code

Are you fully licensed or practicing under supervision?

Yes No

Are you currently accepting new clients?

Yes No

Do you offer telehealth, in‑person, or both?

In-Person

Telehealth

Please list your professional credentials (e.g., LPC, LCPC, LPCC, LMHC, LCMHC, etc.)

What days and times generally work best for you?

Please share your current clinical setting

Please describe the populations you serve

Please describe your approach, and the modalities you use in your work

Please list any insurance providers with whom you are paneled, if you accept cash-pay, or superbills

Is there anything else you’d like us to know before we reach out?

How did you hear about us?

Would you be interested in working with us in the future?

Your information will be encrypted.