Client Referral
Provided by: Wellness Grove
Referring Contact Name
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First Name
Last Name
Referring Organization Name
Referring Contact Phone Number
*
Extension
Referring Contact Email Address
*
Confirmation Email
example@example.com
Client Date of Birth
*
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Month
-
Day
Year
Current Date
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Month
-
Day
Year
Client Age
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Client Legal Name
*
First Name
Middle Name
Last Name
Client Preferred Name
Client Phone Number
*
Client Email Address (if available)
Confirmation Email
example@example.com
Back
BEGIN
Please describe the reasons why the client is being referred to Wellness Grove
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If possible, please check the areas of counseling that may relate to the reasons why a referral is being submitted for the client
Abuse
Academic Issues
Adjustment & Life Transitions
Adolescent Issues
Aging & Geriatric Issues
Anger Management
Anxiety
Blended Family
Body Image
Bullying
Burnout
Career Development
Caregiving Issues
Chronic Health Issues & Disability
Chronic Pain
Communication & Conflict Resolution
Coping Skills
Depression
Divorce
Family Conflict
First Responder Issues
Gender Dysphoria
Girls’ & Women’s Issues
Gratitude
Grief & Loss
Intimate Partner Violence
LGBTQ+ Issues
Meaning & Purpose in Life
Military Issues
Pandemic Counseling
Panic Attacks
Parenting
Perfectionism
Pregnancy & Postpartum
Relationship Issues
Self-Criticism
Self-esteem
Self-harm
Spirituality
Strengths
Stress
Substance Use Issues
Suicidal Ideation
Trauma & PTSD
Wellness
Other
Back
Next
Acknowledge & Sign
By signing this form electronically and clicking on "Sign & Submit", you are certifying that the information given on this form is true and correct to the best of your knowledge. You are also acknowledging that you have spoken with the client and they are aware and have given permission for this referral to be submitted on their behalf. The client understands that a Wellness Grove representative will contact them to discuss counseling services. Please note that an e-signature is the electronic equivalent of a hand-written (pen-and-paper) signature.
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Input Your Legal Name
*
Date
*
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Month
-
Day
Year
Sign & Submit
Should be Empty: