Sonder Hope Counseling LLC.

Seeking Services For A Client or Patient?

Submit a Referral Inquiry Below

After reviewing the information, I will follow up with you regarding next steps.
Please do not include client PHI details and only include minimum required information. This is not a HIPAA-secured form and is for general inquiries only.
Note: this form is for professional referrals only and should not be utilized by personal friends/family or client-to-client referrals.
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Name of Referring Party *

First

Last

Organization/Company of Referring Party *

Referring Party Email *

Client of Referring

Referring Party Phone Number *

Referring Party Relation to ClientPrimary Care PhysicianCurrent or Previous Counselor/TherapistCase Manager/Social WorkerOther

Inquiring About *

• Individual Counseling
• Couples’/Relationship Counseling
• Unsure/Still Gathering Information

Without including any PHI, please briefly describe the services your client/patient is seeking. *

Please include enough detail for me to determine if I can meet their needs WITHOUT including any PHI information that would violate HIPAA standards. This is not an encrypted message service and is used for general referral inquiries only.

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