Make a referral

CVIC therapists provide evidence-based, trauma-informed support to survivors of domestic/family violence, sexual violence, stalking and bullying. This includes children who are exposed to violence in their homes.

Therapy Referrals

REFERRAL SOURCE
Agency*
Referrer Name*
First Last
Phone
Email*
CLIENT INFORMATION
Name*
First Last
Gender
- Male
- Female
- Other
Birthdate*
MM slash DD slash YYYY
School Attending (if applicable)*

If client does not attend school, please indicate with N/A
Grade
Client Email
May we contact the client using this email address?
If the email address is shared with or monitored by another person, it may not be safe or confidential to contact the client in this way.
Client Phone Number*
May we leave a voicemail at this number?*
May we unblock our number before calling?*
What is the best time of day to contact you?*
Address*
Street Address City State / Province / Region ZIP / Postal Code
PARENT/GUARDIAN INFORMATION
If client is under age 18, please provide this information.
Name
First Last
Phone Number
May we unblock our number before calling?
May we leave a voicemail at this number?
What is the best time of day to contact you?
Address (if different than client address)
Street Address City State / Province / Region ZIP / Postal Code
REASON for REFERRAL
Type of Violence Experienced*
Approximate Date of Incident(s)*
MM slash DD slash YYYY
Briefly Describe*
Is the client open to seeing a remote therapist via Zoom?
Do you have access to internet and a private location for sessions?*
Please explain what your needs are.
(For example, you need to come to CVIC to access Zoom to meet with a remote therapist).
Other Professionals Involved in Client's Care
Please list name and affiliation of other professionals involved in this client's care.*
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Make a referral

Therapy Referrals

REFERRAL SOURCE

CLIENT INFORMATION

PARENT/GUARDIAN INFORMATION

REASON for REFERRAL

Other Professionals Involved in Client's Care