Counseling Center Referral Form

Counseling Center Referral Form
Disclaimer

This referral form is intended for outpatient counseling services only. Our office hours are Mondays-Thursdays from 8am-5pm and Fridays from 8am-3pm, unless otherwise listed on our website or social media sites. Pivot, Inc does NOT provide crisis stabilization services, inpatient services, psychological evaluations, or medication management services. This form is also NOT monitored 24/7. If you or a loved one is experiencing immediate suicide/mental health crises, please contact 988 or text "HOME" to 741-741. For immediate medical emergencies, please contact 911 or go to your nearest emergency room.
Please fill out each section below to the best of your ability. The sections can be expanded by clicking the arrow button on the right-hand side of the header.
- SelfFamilyProvider/AgencyOKCPDSchoolPivotOther
- YesNo
- If this is NOT a self-referral, please complete the information below.
- Name of Person Completing This Referral
  
  First NameLast Name
- Referring Person's Relationship to Client
- Referring Person's Phone Number
  Please enter a valid phone number.
- Referring Person's Email Address
  example@example.com
- Client's Name*
  
  First NameLast Name
- Client's Phone Number
  Please enter a valid phone number.
- Client's Email Address
  example@example.com
- Client's Date of Birth*
  
  MonthDayYear
- Client's Age*
- Client's Social Security Number
- Client's Insurance Provider
- Client's Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- If this is under the age of 18, please complete the information below.
- Name of Client's Parent/Legal Guardian
  
  First NameLast Name
- Parent/Legal Guardian's Relationship to Client
- Parent/Guardian's Phone Number
  Please enter a valid phone number.
- Parent/Guardian's Email Address
  example@example.com
- Brief Problem History*
  Why are you seeking counseling services now?
- Desired Goals for Counseling*
  What do you hope to get out of counseling services?
- Provider Preference (if available)
- YesNo
Should be Empty:

Counseling Center Referral Form

Disclaimer