Provider Referral form

Dear Community Partner,

Thank you for your interest in Sproul Counseling & Consulting, LLC.

To refer your active client/patient, please complete the form below.

Kindly refer your client/patient to the appropriate level of care. We accept adults who seek individual counseling who reside in Oregon or New Jersey. Pls. include a signed Release of Information for all referrals.

We refer helpseekers in acute psychiatric crisis to the crisis line of the county of their residence or the nearest ER. In Portland these resources include

Multnomah County Crisis Line, 503-988-4888
Washington County, Oregon Crisis Line, 503-291-9111
Clackamas County Crisis Line, 503-655-8585
Unity Center for Behavioral Health,1225 NE 2nd Ave, Portland, OR 97232, 503-944-8000, Fax: 503-944-8011
Providence Portland Emergency Department, 4805 NE Glisan St, Portland, OR 97213, 503-215-1111
Providence St. Vincent Emergency Department, 9205 SW Barnes Rd, Portland, OR 97225, 503-216-1234

Thank you.

Provider Information

Practice/Clinic Name

Provider

Sender

Contact Information

Phone

HIPAA compliant fax

Reason for referral

Individual expressed interest in outpatient counseling services

Individual receives medication management from provider

Individual would benefit from adjunctive counseling

Psychoeducation

state below

Other

state below

Provider Note

Pls. attach relevant PHI including: release of information for referral, medication list, last treatment note, if available. Or fax to (971) 277-7694

Add file

Please upload a file

Individual Referred

First Name

Last Name

Date of Birth

Email address

Phone number

Days of the week you are available for appointments I see clients Monday through Friday

Any week day

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

It varies

Times you are available I see clients between 9 and 4:15 pm most days. I am closed evenings and weekends.

9 am - 12 pm

1 pm - 4:15 pm

It varies

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