Referral Form | Spokane Counselor

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Contact Us

Please note we do not provide medication management at this time.

First name*

Last name*

Email*

Phone*

Due to the high number of referrals that we receive, we utilize email most often to respond to perspective clients. Please keep an eye out for our response!

Presenting Concerns

Multi choice*

Anxiety

Depression

Trauma/PTSD

Grief/ Loss

Relationship/Family issues

Child/Teen Concerns

Perinatal/ Postpartum

EMDR

ADHD

Other

Additional info/comments:

Hospitalized within the past year?

Format/location

In person or telehealth:*

Location*

Provider Preference

Multi choice*

Male provider

Female provider

No Preference

If there is a specific counselor you are interested in seeing, please indicate who that is. We will let you know if they have openings.

Payment Options

Cash pay (no insurance)

Insurance

What insurance do you have?

Do you have secondary insurance? If Yes, please provide that info as well.

What is the age of the person seeking services *some of our providers only work with certain age groups:

Age*

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