Referral Form

The Canvas of Life Counseling, LLC is a small private outpatient group practice designed to support individuals who can engage in counseling independently within a traditional outpatient therapy model. Clients with higher acuity needs, such as those requiring frequent monitoring, intensive support, or comprehensive care teams, may be better served in a setting equipped to provide that level of care such as large agencies, or facility-based programs. Our priority is to ensure each client receives the most appropriate and effective support for their needs. If you have any questions about the appropriateness of receiving services at our practice, please email us at [email protected].

Submit a Referral

* Indicates required field

Client's Name *

First

Last

Client's Date of Birth (we do not work with clients younger than 5 years old) *

Client/Guardian's phone number *

Client/Guardian's Email *

Scheduling availabilities (days/times) *

Preference for In-person, Telehealth, or hybrid format (List first and second preference please) *

Briefly share the client's symptoms/reasons for seeking services *

Insurance provider name or self-pay (we are not in-network with Cigna or Aetna but can offer superbills) (We cannot bill Medicare/Medicare Advantage Plans/Optum Plans such as, UHC, UBH, & UMR for our conditional providers) *

If a licensed provider is not available, would the client be open to working with a clinical intern? (this service has a low administrative fee of $36.00 per visit to fund the internship program) *

Name(s) of preferred provider(s) if any *

Submit Referral