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Refer a Client to Soulful Oasis Wellness

This form is intended for physicians, nurse practitioners, psychologists, psychotherapists, social workers, school professionals, community agencies, victim-service professionals, lawyers, and other professionals wishing to refer an individual for psychotherapy or related mental health services.

If this is an emergency or there is an immediate risk of harm, please do not use this referral form. Contact 911 or the appropriate local emergency/crisis service.

Fields marked optional may be left blank.

Referring Professional

Preferred method of communication

Client Information

Preferred Method of Contact
May Soulful Oasis Wellness identify itself when contacting the client?

Reason for Referral

What is the primary reason for this referral?

Service Requested

Please select any services you are requesting or believe may be appropriate:

Relevant Information

Please provide any information that may assist with appropriate intake, triage, or treatment planning.

Is the client currently receiving mental health services from another provider?

Safety & Urgency

How would you describe the urgency of this referral?
Are you aware of any current safety concerns relevant to this referral?

This referral form is not monitored as an emergency or crisis service. If there is an immediate risk of harm or a medical or psychiatric emergency, please contact 911 or the appropriate emergency/crisis service.

Client Consent

Has the client agreed to this referral?
Has the client agreed to be contacted by Soulful Oasis Wellness regarding this referral?
Has the client authorized you to provide the information contained in this referral to Soulful Oasis Wellness?

Communication With Referring Professional

May Soulful Oasis Wellness contact you if clarification regarding this referral is required?
Would you like confirmation that the referral has been received?

Submission of a referral does not establish a therapist-client relationship, guarantee acceptance for treatment, or confirm that a particular service or clinician is appropriate or available. Clinical suitability and service availability will be determined through the intake process.