Healthcare Provider Referral Form

Provider Referral Form

Stellar Insight Counseling provides LGBTQ+ and ADHD/Autism affirming counseling services for the following issues: anxiety, depression, PTSD, insomnia/difficulty with sleep, and perinatal/postpartum counseling.

Referral Source/ Provider Name

Provider/Referral Source Email address

Provider/ Referral Source Phone Number

Client Name

Client Contact Information

Please provide the best way to contact the client (phone call, text, or email)

Additional Information You Wish to Provide:

Files (optional)

Add file

Please upload a file

If your client has signed an ROI, are you interested in coordinating care?

(ROI would need to be verified)

Thank you for taking the time to complete this form. Please allow 2-3 business days for a reply. May you find joy in your day.

Nicole Zegiestowsky, M.S. (she/her)

Stellar Insight Counseling

Phone (call/text): 907-744-7026

Email: nicole@stellarinsightcounseling.com

I am thankful to live, work, and play on lands traditionally cared for by the Dena’ina Ełena cultural group.

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