Submit Referral

Person Referring Patient & Relationship to Patient

Patient's Name

Patient's Insurance Name, Insurance Customer Service Number, and Policy Number (if patient is not the primary subscriber, please also add the name of the subscriber and their date of birth). If the patient also has secondary insurance, please include that below

Patient's Phone Number

Patient's Home Address (include City, State, and Zip Code)

Patient's Email Address

Does the patient have a history of or present thoughts of suicidal or homicidal ideation? If yes, please explain

Patient's Preferred Days and Times For Appointments

Overcoming Life's Obstacles Counseling

Scheduling an Appointment

Please complete the form below to refer a patient to our practice. You will receive a response once your referral is reviewed.