Referral for services

This form is to streamline referrals for therapeutic services. Please ensure all sections are completed thoroughly.

Referral Source information

First Name

Last Name

Phone

(###)

###

####

Agency (if applicable)

Client Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

YYYY

Gender

Male

Female

Non-binary

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is this client. a minor?

Yes

If client is a minor, do you have legal custody?

Yes

Parent/Guardian Information

First Name

Last Name

Relationship to client

Phone

(###)

###

####

Insurance Provider

Policy Number

Reason for referral (Please provide detailed information relevant to the treatment needs of the client being referred. This information will enable the clinician to determine the most appropriate modality for ef ective intervention. For example: "Jane Doe experiences significant challenges in regulating her mood during periods of distress. Recent interpersonal interactions have been marked by verbal altercations. It is recommended that she be provided with an outlet to express her thoughts and feelings, which may assist in coping with life's stressors.")

Referral for services

eMbrace Therapeutic Services

Accepted Insurance:

Contact