Therapy Services

Referral Instructions

Please complete the referral form below to request therapy services. Our therapy services offer a confidential and supportive space for individuals seeking emotional support, personal growth, and improved well being. Services are individualized to meet each client’s unique needs, goals, and strengths.

Therapy may address concerns such as stress, anxiety, depression, trauma, relationship challenges, life transitions, emotional regulation, and overall wellness. Our clinicians use trauma informed, strengths based, and evidence based approaches to support healing, resilience, and sustainable change.

Once the referral form is submitted, our team will review the information and follow up with the client to discuss next steps, therapist availability, scheduling, and payment options unless otherwise noted in the additional notes section. All information shared is kept confidential in accordance with professional and legal standards.

If you have questions or need assistance completing the referral form, please contact our office for support.

Therapy Referral

This field is for validation purposes and should be left unchanged.

Client Information

Full Name(Required)
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Your Email Address(Required)
Address(Required)
When is the best time for us to reach you via telephone?

Parent/Guardian Information (if Applicable)

Full Name
Your Email Address

Case Professionals Information (If Applicable)

Full Name
Case Professional Email Address

Insurance Information

Does this client have Medicaid?(Required)

Service Information

Services Needed(Required)
Transportation Needed?(Required)
How did you hear about us?(Required)

Consent + Agreement

I hereby confirm that the information provided above is true and accurate. By typing my name below, I acknowledge that it serves as my electronic signature.
Consent(Required)
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