Make A Referral

Use this form if you are a health or wellness professional and would like to make a referral to Truly Connected Counseling and Art Therapy.

Form is secure and encrypted for HIPAA compliance.

* Required fields

Client's Name *
Client's Name
Parent's Name *
Parent's Name
Parent's Phone *
Parent's Phone
Which services do your feel your client would benefit from? *
Your Name (so I can thank you!) *
Your Name (so I can thank you!)
Your Phone *
Your Phone