Client Referral Form

Please use this form when referring a client to AnchorPoint Counseling, PLLC for counseling or supportive services.

This form is intended primarily for professionals, including county workers, caseworkers, social workers, CSA/FAPT teams, healthcare providers, school professionals, and other community professionals.

Please provide the information below as accurately as possible so our team can review the referral and determine appropriate next steps.

Thank You, AnchorPoint Counseling Team.

I understand that this form is intended for professional client referrals and that I am submitting this referral in my professional capacity.

Referring Professional

First Name

Last Name

Professional Title/Role

Agency/Organization

Phone

Preferred Method of Contact

Phone Call

No Preference

Client Information

Client First Name

Client Last Name

Client Date of Birth

Month

Day

Year

Client Email

Client Phone

Is the client a minor?

Yes

Parent/Legal Guardian Name

Parent/Legal Guardian Phone

Parent/Legal Guardian Email

Reason for Referral

You can select more than one option for the questions below:

Briefly describe the reason for referral and the client's current needs:

Desired Services

You can select more than one option for the questions below:

Mental Health & Treatment History

You can select more than one option for the questions below:

Client Preferences

You can select more than one option for the questions below:

Preferred Modality

In-Person

Home Based (CSA/FAPT ONLY)

Telehealth

Billing & Program Information

Please Be Sure Funding Is Approved

How will services be funded?

Self Pay/Out-of-Pocket

County Funding (CSA/FAPT ONLY)

Employee Assistance Program (EAP)

I'm Not Sure Yet

Funding Approval Status

Approved

Pending

Not Approved

Unknown

Funding Program / Case Information

Referral Details

You can select more than one option for the questions below:

What would you like AnchorPoint Counseling to assist with?

Other Client Information

Is there anything the practitioner or AnchorPoint Counseling Intake team should know about this referral?

Referral Acknowledgment

I am submitting this referral in my professional capacity and have appropriate authorization to provide the information included in this referral.

I understand that submitting a referral does not guarantee acceptance for services or establish a therapist-client relationship.

Important Information

Please do not include payment card information, passwords, Social Security numbers, or other unnecessary sensitive information in this form.

If you are experiencing a medical emergency, call 911. If you are experiencing a mental health crisis, call or text 988.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Client Referral Form

Please use this form when referring a client to AnchorPoint Counseling, PLLC for counseling or supportive services.

Please provide the information below as accurately as possible so our team can review the referral and determine appropriate next steps.

Thank You, AnchorPoint Counseling Team.

I understand that this form is intended for professional client referrals and that I am submitting this referral in my professional capacity.

Referring Professional

Professional Title/Role

Please select the globe icon to the left to select your country (e.g., +1 United States) before entering your phone number.

Preferred Method of Contact

Phone Call

No Preference

Client Date of Birth

Month

Day

Year

Is the client a minor?

Yes

Parent/Legal Guardian Name

Parent/Legal Guardian Phone

Parent/Legal Guardian Email

You can select more than one option for the questions below:

Briefly describe the reason for referral and the client's current needs:

You can select more than one option for the questions below:

Mental Health & Treatment History

You can select more than one option for the questions below:

Preferred Modality

In-Person

Home Based (CSA/FAPT ONLY)

Telehealth

Billing & Program Information

Please Be Sure Funding Is Approved

How will services be funded?

Self Pay/Out-of-Pocket

County Funding (CSA/FAPT ONLY)

Employee Assistance Program (EAP)

I'm Not Sure Yet

Funding Approval Status

Approved

Pending

Not Approved

Unknown

Funding Program / Case Information

You can select more than one option for the questions below:

What would you like AnchorPoint Counseling to assist with?

Other Client Information

Is there anything the practitioner or AnchorPoint Counseling Intake team should know about this referral?

Referral Acknowledgment

I am submitting this referral in my professional capacity and have appropriate authorization to provide the information included in this referral.

I understand that submitting a referral does not guarantee acceptance for services or establish a therapist-client relationship.

Important Information

Please do not include payment card information, passwords, Social Security numbers, or other unnecessary sensitive information in this form.

If you are experiencing a medical emergency, call 911. If you are experiencing a mental health crisis, call or text 988.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.