Referrals

For professionals seeking a trusted space to refer their mental health patients, our practice stands as a beacon of comprehensive and compassionate care. Every individual is met with a team dedicated to their unique needs and therapeutic journey. We offer a range of specialized services, from individual and career therapy to couples/family dynamics and group sessions. Ensuring seamless transitions and continuity of care, we prioritize collaboration with referring professionals, keeping the lines of communication open and feedback loop tight. Trust in us to uphold the standards of care and dedication that your patients deserve.

Referral #

First Name

Last Name

Service Type

Platform

Date of Birth

Insurance after EAP

Yes No

Insurance Name

City

State

Company Name

Sessions Authorized

Start Date

End Date

Coordinator’s Name

Contact Info

Attach Files and Insurance Card Photo

Contact Us

It’s important to remember that many people have mental health concerns from time to time. You are not alone in this. A mental health concern becomes a mental illness when ongoing signs and symptoms cause frequent stress and affect the ability to function. Send us a message anytime and let us know how we can help.

Indicate your Name:

Contact Email:

Phone number:

Reason for your Call/ Visit (Personal, Couple, Family, Employment Program)

Will you prefer to be seen in person?

Yes No

Telehealth/ Virtual Meet?

Yes No

Preferred Time for Appointment:

Morning Afternoon Evening

THERAPY HEALTH CLINIC PLLC

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