Referral Form

Referral Source Information

Client Information

Does the patient have insurance coverage?
YesNoOther

If yes please indicate insurance company

Please indicate annual coverage amount

Presenting Concern

Anxiety / PanicDepression / Low MoodTrauma / PTSDPostpartum / Perinatal ConcernsADHD / Executive FunctioningRelationship / Family IssuesGrief / LossStress ManagementSelf-Esteem / IdentityOCD / PhobiasOther

Brief Description / Relevant History

Medication and Other Considerations

No known risk concernsSuicidal ideationSubstance use concernsMedical / neurological conditions relevant to therapyCurrent MedicationsOther considerations

Requested Service Type

Individual TherapyCouples TherapyFamily TherapyAdolescent / Child Therapy

Preferred Therapist (if applicable)

Preferred Modality (if applicable)
In-personVirtual

By submitting this referral, I confirm I have permission to share this information for the purpose of connecting the client with services, and I consent to Vital Minds Psychotherapy contacting the client (or guardian) directly by phone, text, or email.