Client Portal & Referral Form

Name

Email Address

What are you seeking counseling for? Which 2 clinicians would you be most interested in working with? If you have insurance, please state what health insurance carrier/plan you have and provide your member number so we can verify your coverage.

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Submit" you agree to hold The Compassion Collaborative harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.