Referrals

Submitting a School-Based Referral? Click Here

Provider Referral Form

Thank you for referring a client to our services. Please complete the form below with the necessary information about the individual you are referring. This will help us assess their needs and provide the appropriate care. We appreciate your collaboration in supporting your clients' well-being.

Your Name

First Name

Last Name

Your Email

Your Phone Number

(###)

###

####

Client Name

First Name

Last Name

Client Email

Client Phone Number

(###)

###

####

Primary Reason for Referral

Additional Information/Notes

Referrals

Provider Referral Form

Thank you for your referral!

Counseling Wellness & Health, PLLC

Location

Contact