Professional Referral FormTrue to Herself Therapy for Girls and Women

Professional Referral Form

Thank you for your referral to True to Herself Therapy for Girls and Women. Please complete the information below to help us determine whether services may be an appropriate fit for the referred client’s needs.

Referring Individual Information

First and Last Name of Person Submitting Referral

Organization / Practice Name (if applicable)

Email of Person Sending Referral

Phone Number of Person Sending Referral (format: no dashes)

Client Information

Client/Patient First and Last Name

Parent or Caregiver First and Last Name

Client/Patient Date of Birth (format: month/day/year)

Patient/Client Phone Number (format: no dashes)

Patient/Client Email Address

Insurance Type of Person being referred

Reason for Referral or Presenting Challenges

Today's Date required

Important Notice

Submission of this referral form does not guarantee services or establish a therapeutic relationship. All referrals are reviewed to determine clinical appropriateness, service fit, and provider availability.

Please note that True to Herself Therapy does not provide custody evaluations, visitation recommendations, or court-related services.

Thank you for your referral and for trusting True to Herself Therapy as a potential support resource. A member of our team will reach out to the referred individual or parent/guardian as appropriate. You are also welcome to share our direct contact information with the client or parent:

Phone: 864-332-9956
Email: info@truetoherselftherapy.com