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, Option 1 if you have any questions regarding this form.


TTHI Counseling Center

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