For Providers

You care about your patients and you want to make sure that anyone else involved in their treatment cares too.

I believe collaboration is key to successful treatment of physical and mental health, and I’ll work with you to keep you informed of your patient’s progress and needs along the way.

Feel free to fill out the form below on behalf of your patient. I will contact them within a business day. Once I make contact with them, I can reach out to you to let you know what steps were taken and how I plan to follow up.

Find the referral form here

Need some help talking with your patients about their relationship needs and emotional needs? I’ve created a screening questionnaire you can go over with them to help understand their needs and determine if therapy could help.

I’ve also created a letter for your patients experiencing infertility issues. Feel free to discuss it with them to help you both understand what they may be experiencing.

*This screening questionnaire is not intended to be a diagnostic tool. It is simply a list of questions to help you identify specific relational, emotional, and mental health issues they may experience.

Questionnaire

Infertility Letter

Patient Referral Form

Provider Information
Provider's Name*
First Last
Provider's Email*
Patient Information
Patient's Name*
First Last
Patient's Email*
Patient's Phone Number*
Briefly Describe the Reason for Referral:
Email
This field is for validation purposes and should be left unchanged.

For Providers

You care about your patients and you want to make sure that anyone else involved in their treatment cares too.

*This screening questionnaire is not intended to be a diagnostic tool. It is simply a list of questions to help you identify specific relational, emotional, and mental health issues they may experience.

Patient Referral Form

Provider Information

Patient Information

Or, you can fax me a referral form at (864) 408-8520, ATTN: Jessica Fairfax.