Professional/Medical Referral Form

Patient Referral Form

Professional/medical referrals please complete this form. We will reach out to the client promptly for scheduling. Please call us at (602) 456-4150 if you would like to discuss the referral in more depth.

** We currently only accept patients age 12+**

"*" indicates required fields

Patient First Name*

Patient Last Name*

Email*

Phone*

Patient is aware that this referral is being made and has agreed to be contacted by Wiser Counseling**

Yes

Referring Provider Information

Name of Referring Provider*

Referring Provider Company*

Referring Provider Email*

Referring Provider Phone*

Client Information

Which service(s) is the client interested in?*

To select multiple options, hold down control or command when making your selection

What is the client seeking services for?*

Is there anything else you would like to share? (i.e. Client diagnosis, scheduling preferences, etc...)

Teen Therapy
Individual Therapy for Adults
Couples Therapy
Family Therapy
EMDR Therapy
Ketamine-Assisted Therapy

Anxiety
Couples Therapy
Depression
Grief and Loss
Military/Veteran Issues
Life Transitions
Perinatal Mood and Anxiety Disorders (Pregnancy
Postpartum
Relationship Issues
Trauma/PTSD
Other