REQUEST COUNSELING

Refer a client

Rather call us? To get assistance from our administrative staff with scheduling your first appointment with Holistic Elevation,

call (302) 278-0026. Staff are available Monday-Friday from 8:30-5pm.

Client's name

DOB

Age

Client's Address

Phone

Email

If client is under 18 or has a guardian, provide contact information for parent or guardian

Parent/Guardian Email Full Name (if client is a Minor)

Parent/Guardian Email

Parent's Phone

Parent's Address

(If Different)

Additional Information

Is the client / parent / guardian aware of this referral?

Best Contact Method

Client's Insurance Information

Referring Personnel/Organization Information

Individual making this referral (please print):

Agency's Name

Phone #

Fax

Email Address

Reason for Referral:

Do you know the driving force?

What is the driving force of their current situation:

Environmental Impact (living in a toxic community or household)

Situational Impact (Returning to unhealthy situations, e.g., homelessness, bullying, domestic violence, human trafficking)

Event: This person witnessed a sudden event that has altered their life. e.g. sudden death of a loved one, non-genetic medical diagnosis

Genetic/Medical (does the potential client's family or medical impact their health or a result of the event's prolonged impact)

For more information

Return Complete Forms to:

Mail: Holistic Elevation LLC,

Attention: Intake

3700 Lancaster Ave, Suite 303. Wilmington, DE 19805

Phone: 302-278-0026 FAX: 302-278-0047 or EMAIL: intake@holisticelevation.org