START A REFERRAL
logo
  • Home
  • Services
    • Online Counseling
    • Early Childhood Mental Health
    • Incredible Years
    • Training and Consultation
    • EMDR
    • IHTS
    • School-Based Therapy
    • Trauma-Focused Cognitive Behavioral Therapy
    • Play Therapy
    • My Body is Mine
    • Individual, Group and Family Therapy
  • About
    • Our Story
    • Our Staff
    • Job Opportunities
    • FAQs
    • Attendance Policy
  • COVID-19 Resources
  • REFERRAL FORMS
  • News
  • Contact
  • Employee Site
MENU

REFERRAL FORMS

Online Counseling

If you are a new client, you must fill out referral form first. Click here to review and sign online counseling consent and agreement to pay form.

Sign Consent

PROFESSIONAL REFERRAL FORM

If you are a professional provider wanting to make a referral for outpatient services, please use this referral form.

Start Referral

SELF REFERRAL FORM

If you are an individual or parent looking to make a referral for yourself or your child, please use this referral form.

Start Referral

IHTS Referral Form

If you are a professional provider looking to refer an individual who qualifies for our In-Home Therapy Services (IHTS) program, please use this form.

Start Referral

PDF Referral Form

Use this link to download our old fillable PDF referral form that can be emailed or faxed.

Download PDF

SPANISH REFERRAL FORM

If you want to make a referral for yourself or your child, please use this referral form.

Start Referral

All information submitted with this application is completely confidential, secure and encrypted. After you submit the secure form, you will be emailed a copy for you records.  Click here to see our attendance policy.


OUR TEAM

OUR STORY OUR STAFF

LEARN MORE

FAQs ATTENDANCE POLICY REQUEST INFO PROFESSIONAL REFERRAL FORM SELF REFERRAL FORM

CONTACT

(336)899-8800 Hours: Mon-Fri: 8AM to 5PM OUR OFFICE LOCATIONS JOIN NEWSLETTER
Crafted by Zibster
logo
CLOSE
  • Home
  • Services
    • Online Counseling
    • Early Childhood Mental Health
    • Incredible Years
    • Training and Consultation
    • EMDR
    • IHTS
    • School-Based Therapy
    • Trauma-Focused Cognitive Behavioral Therapy
    • Play Therapy
    • My Body is Mine
    • Individual, Group and Family Therapy
  • About
    • Our Story
    • Our Staff
    • Job Opportunities
    • FAQs
    • Attendance Policy
  • COVID-19 Resources
  • REFERRAL FORMS
  • News
  • Contact
  • Employee Site
START A REFERRAL