Secure Referral Form

I acknowledge that this referral is a request for services only and does not establish a therapist-client relationship or guarantee acceptance into care. Healing with Grace will review the referral, obtain any required authorizations before disclosing protected health information, and notify me if the referral cannot be accepted. I confirm that I am authorized to submit this referral and that the information provided is accurate to the best of my knowledge.*

I understand that Healing with Grace is a self-pay practice and that payment arrangements and fees will be discussed directly with the prospective client before services begin.*