Please note:

  • ALL of the information on this form must be complete in order for the referral to be processed.
  • If there is a question that does not apply to the adult/child/adolescent you are referring, please put N/A.
  • If there are reports, notes, other evaluations, etc. pertaining to this referral, please attach them to this form.
  • Please feel free to contact us at 407-892-5700 x160 or x161 if you have any questions regarding this form.

 

TTHI Counseling Center

Refer a Patient

 

Submit Your Referral