Referring Professionals | Elevate Counseling C

Professional Provider Referral Form

Thank you for trusting Elevate Counseling & Consulting with your client’s care. If you are a healthcare provider, school professional, therapist, attorney, or other community partner looking to connect someone with mental health services, you can submit a referral using the secure form below.

Please provide the information available to you, including any relevant concerns, service needs, or therapist preferences. Our team will review the referral and work to connect the client with the provider who best fits their needs and availability.

Please do not use this form for emergencies or immediate safety concerns.

To get started please provide all information requested in the below.

Duplicative information is unnecessary on the form if information is present in the uploaded documents.

Provider Referral

Referring Professional Name and Place of Business

Client Legal First Name

Client Legal Last Name

Client DOB

Client Address

Client Phone

Provider Preference

Primary Insurance Company

Reason for Seeking Counseling

Provider Email for Confirmation of Referral

By submitting this form, you agree to the processing of this clients sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.

By submitting this information, you consent to you or your client being contacted by this practice via email, phone, voicemail, or text.

I confirm that my client is aware of and has consented to this referral and the sharing of their information with Elevate Counseling & Consulting.

Release of Information upload

Other Client File Upload