Referral Form

Thank you for reaching out to Humanity First Counseling for your client's mental health evaluation needs.

Please fill out the brief, confidential referral form that follows and we will follow up with the client within 24 hours.

If you have specific questions or concerns, you may indicate these in the open-ended text section at the bottom of this form. You may also upload a declaration or other relevant forms.

Thank you, and do not hesitate to mention if you would like us to follow up to discuss any specifics of the case!

Most Sincerely,

Humanity First Counseling

Referrer

First NameLast Name

Referrer Organization

Referrer Phone

Referrer Phone (alt)

Referrer Email

example@example.com

Type of Referral*

*Please note we are not currently accepting referrals for cases that require testimony.

Notes on Referral Type As Needed:

Client Is A Minor?

Client Gender

Notes on Gender and/or Client's Preferred Gender Pronoun As Needed:

Client

First NameMiddle NameLast NameSuffix

Contact Phone

Contact Email

example@example.com

Alt Contact (if different than client named above)

First NameLast Name

Any additional contact info:

Do other family members need to be interviewed for this report?

Do other family members require their own separate reports?

Client's City of Residence

Client's Native Language

Any other important information:

Please upload declaration or any other relevant files: