Referral Form

Client's Name: *

First

Last

Client's date of birth: *

Name of person completing this form? *

First

Last

Client's Email *

Relationship to client? *

Email of person completing this form? *

Client's phone number? *

Guardian's phone number? *

Client's sex at birth: *

Client's gender identity and preferred pronouns: *

Client's Address *

Line 1

Line 2

City

State

Zip Code

Country

Symptoms and reasons for seeking services: *

Insurance provider or self pay for services: *

Previous/Current mental health/substance use diagnosis, if any: *

Scheduling availabilities during the week (i.e. days and times that would work best): *

Session format preferred: *

In-person only Telehealth only Hybrid approach of both

Current Medications and name of prescribing provider: *

Additional information that is pertinent for the provider to know: *

List which providers the client is open to working with: *

Tiffany Manson, LCPC, CADC, CGP Lynn Walkiewicz, Ph.D., LMSW-CC Tracie Giambra-Vye, LCPC-c, LSW Casie Rizza, Clinical Intern (Telehealth & Self Pay only) Chelsea Cloutier, LADC (offers substance use services only) Melissa Woody, Clinical Intern (Self-pay only) (Telehealth & Some in person) Waiting List for individual therapy with a licensed provider Waiting List for individual therapy with a clinical intern Waiting List for group therapy

Submit a Referral