This referral form is intended to facilitate connecting individuals with a licensed mental health therapist. All information provided will be treated as confidential and used solely for processing the referral; however, confidentiality may be limited in cases where disclosure is required by law, such as threats of harm to self or others. Please note that this form is not intended for emergency situations.

If you or someone you know is in crisis, contact emergency services or a crisis hotline immediately. Completing this form does not establish a therapist-client relationship, and the information provided will be reviewed to determine appropriate next steps based on professional judgment. While we strive to connect individuals with the necessary services, submitting this form does not guarantee acceptance as a client or immediate availability of services. By proceeding, you acknowledge that the information provided is accurate to the best of your knowledge and that you understand and agree to these terms. For questions or concerns, please contact us.