Request an Appointment

Emergency Assistance

If this is an emergency, call:

Crisis Line: 988

Client Information

First Name

Last Name

Sex as listed on insurance policy

Gender

preferred pronouns (i.e. she/her)

DOB

Age

First Name (parent/guardian)

Last Name (parent/guardian)

Phone

Are you making this referral for yourself (or your child/family member)?

Yes

How did you hear about us?

Online search

Insurance search

Friend/family member

Other

Please provide any details

Your Name

Your phone number

Your email address

Your relationship to the client being referred

Service Type

Which service(s) are you interested in receiving?

Individual Therapy

at this time we are only able to accept new referral for clients 12 and older

Couples Therapy

unfortunately we are not accepting new referrals for couples counseling at this time

Family Therapy

unfortunately we are not accepting new referrals for family therapy at this time

Group Therapy

Which service(s) is the client interested in receiving?

Individual Therapy

at this time we are only able to accept new referral for clients 18 and older

Couples Therapy

unfortunately we are not accepting new referrals for couples counseling at this time

Family Therapy

unfortunately we are not accepting new referrals for family therapy at this time

Group Therapy

Insurance Information

Primary Insurance Provider

Member ID

Secondary/Supplemental Insurance

Member ID

Availability for Appointments

Days

Monday

Tuesday

Wednesday

Thursday

Friday

please provide additional details

Preferences

Preferred Appointment Location

in person

virtual (telehealth)

Would you be open to telehealth appointment options if that meant we could get you started sooner?

Yes

Would you be open to working with a graduate level intern if the option was available?

Yes

Would the client be open to working with a graduate level intern if the option was available?

Yes

Reason for Appointment

please provide a brief explanation of the issues you are looking to have addressed, as well as any additional details you would like us to know about what you are looking for

please provide a brief explanation of the issues the client is looking to have addressed, as well as any additional details that would be relevant for us to know about the services they are seeking

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Request an Appointment

Emergency Assistance

Client Information

Service Type

Insurance Information

Availability for Appointments

Preferences

Reason for Appointment

Emergency Assistance

Compassionate Counseling Company