Referral Form

* Please allow up to 72 hours for follow-up. *

Client Information

Date of referral

First Name *

Last Name *

Street Address

City

State/Province

ZIP / Postal Code

Country

Client Email *

Client Phone

Date of Birth

Client Social Security Number

Client Medicaid Number

Sex

Race

Primary Language

School & Grade (if applicable)

If not using Insurance, client will:

GUARDIAN INFORMATION

Legal guardian of client is:

Guardian First Name *

Guardian Last Name *

Street Address

City

State/Province

ZIP / Postal Code

Country

Guardian Email *

Guardian Phone

Referral Source

First Name *

Last Name *

Title of Referring Person

Referral Agency

Referral Email *

Referral Phone Number

TREATMENT NEEDS

Insurance Name

Member ID

Group ID

COMMENTS

Welcome to My Tribe Counseling Agency, where our mission is to provide a quality mental health service that meets the needs of you who are experiencing challenges that you are focused on overcoming. We desire to provide a service that you can receive no matter the barriers that may be presented.

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Email

(813) 510-0572
mytribe@mytribecounseling.com