Referrals for Services

Finding a therapist doesn't have to be difficult! You don't even need a referral from your primary doctor first - NO FORMAL REFERRAL NEEDED! We take SELF-REFERRALS as well as referrals from medical offices and other providers.

Please fill out the Referral Form below completely. Once we receive your referral form, we will review your information to ensure that you have the proper insurance providers and then follow up with any questions that we may have and our Registration Packet. We will be able to give you more information regarding therapist availabilities and your individual needs. Looking forward to working with you!

Therapy/Counseling Referral Form

Phone

317-890-5722

admin@innovativeinterventions.org

Who is filling out this form?

If you are filling this form out for YOURSELF, please fill out all of the "CLIENT" fields.

If you are filling out for someone else, please also fill out the "OTHER" fields found below:

CLIENT's Legal Full Name

CLIENT's Date of Birth

CLIENT's Address

CLIENT/GUARDIAN's Email Address

CLIENT's Phone Number

If you are filling out this form for someone else, please fill out the contact information below. If no, please leave blank.

OTHER Party's Full Name

Relationship to Client

OTHER Party's Email Address

OTHER Party's Phone Number

In this next section, please provide some basic details on why you (or the person you are referring) is seeking Counseling Therapy services. We will be able to utilize this information to better place you with the proper provider.

Reason for Referral:

We offer different ways for you to meet with a therapist. Please check ALL options that you are open to:

Virtual/Telehealth Counseling via HIPAA compliant platform

Office Based Counseling

Home Based Counseling

Thank you! We'll be in contact soon!