Provider Referrals

Provider Referral Form

PROVIDER INFORMATION

* Indicates required field

Name *

First

Last

Name of your Hospital/Agency/Practice *

Phone Number *

Email *

Is the client aware that you are making this referral? *

Yes No

What is your relationship to this client? *

If you selected "other", please specify here. *

CLIENT INFORMATION

What services is the client being referred for? *

Does the client have insurance coverage? *

If you selected "other" for insurance, please specify here. *

Please share a few details about the client's needs. (Is this referral for a specific treatment modality such as Brainspotting, EMDR, etc.?) *

Where did you hear about our services? *

If you selected "other", please specify here. *

CLIENT (OR GUARDIAN) CONTACT

Please complete a separate form for each person if you are making more than one referral UNLESS the individuals are a part of the same family unit or couple.

Name *

First

Last

Phone Number *

Email *

If applicable, please list the names of any other individuals included in this referral *

Submit

If the client (or guardian) is unaware you are making a referral on their behalf, instead of submitting a referral, please direct them to fill out our client counseling interest form at https://www.expressiveartsplace.org/counseling.html to ensure that they are okay with us contacting them regarding services.

Counseling
Referrals

Provider Referral Form

Make room for the arts!

Hours

Telephone

Email

Counseling ​Referrals

Provider Referral Form

Make room for the arts!

Hours

Telephone

Email

Counseling
Referrals