Please complete this form to refer a client. The information will be reviewed and follow-up will be provided to coordinate care.

Name

First Name

Last Name

Profession/Title (if applicable)

Organization/Practice (if applicable)

Email

Client Name

First Name

Last Name

Client Date of Birth

MM

DD

YYYY

Client Phone

(###)

###

####

Client Email

Preferred Contact Method

Phone

Email

Reason For Referral

Presenting concerns brief description

Services Requested/Recommended

Individual Therapy

ADHD Support

Emotional Regulation

Assessment/Diagnosis

Other

(if other please provide information)

Message

(Any additional notes/Relevant history)

Consent/Authorization

By submitting this referral, I confirm that I have obtained the client’s permission to share this information with Neuro Notes Mental Health Therapy for the purpose of scheduling and providing services.

Yes

Referring Provider Signature

(First and Last Name)

Date

MM

DD

YYYY

Time

Hour

Minute

Second

Rozell Therapy maintains the privacy and confidentiality of all client information in accordance with HIPAA and professional ethics. This referral form is intended for provider-to-provider communication only and should not include detailed clinical notes or sensitive health information beyond what is necessary for coordination of care.

Submission of this form does not establish a treatment relationship between Rozell Therapy and the referred client. A formal intake process must be completed before therapy services can begin.

If you have any questions about the referral process or would like to discuss client fit, please contact Amanda Rozell, LMHC, directly via email.

Referrals