Today's Date *

MM

DD

YYYY

Person Filling Out Form *

First Name

Last Name

Phone *

(###)

###

####

Client Name: *

First Name

Last Name

Client Phone *

(###)

###

####

Former Client? *

Yes

No

Sex *

Female

Male

Other

Prefer Not to Say

Type of Counseling *

Please select all that apply. If you are seeking individual counseling for more than one person, please fill out a separate referral for EACH person

Individual

Family

Marriage

Play Therapy

Are you comfortable seeing a therapist who may be of a different gender/ethnicity than you? *

If not, please specify in the next box

Yes

No

Payment *

Are you able to self-pay?

Yes

No

Insurance *

Yes

No

Availability (1/2) *

Please select the days of the week that would work best for you for scheduling appointments.

Monday

Tuesday

Wednesday

Thursday

Friday

Any day of the week works for me.

Availability (2/2) *

Please select the times of day that would work best for you for scheduling appointments.

Morning (8am-12pm)

Afternoon (1pm-4pm)

Evening (5pm-8pm)

Any time works for me.