Professional Referral Form - Freedom Within Center | Counseling

Ready To Get Started?

We’re here to make the process as simple and supportive as possible. Choose the option that works best for your patient.

Give Us A Call

Prefer to speak with someone directly? Call us at 619-363-1920 — we’re happy to answer your questions that you might have for your patient..

Schedule a quick call with our Client Care Coordinator to share what you’re looking for. We’ll help match your patient with the right therapist — this isn’t a therapy session, just a chance to get started.

Fill Out Our Form Below

Complete this form, and we’ll reach out shortly to answer any questions and help get your patient taken care of.

To request an appointment, please fill out the form below and our Client Care Coordinator will contact you shortly.

Preferred First Name

Preferred Last Name

Phone Number

Date of Birth

Are You Currently Active Duty Military?

Yes No

Check any of the below that you identify as:

Military Veteran Family Member of an Active Duty Service Member

Is the Potential Client at least 18 years of age?

Yes No

Please note that we only see clients who are at least 18 years of age. If the client is a minor we are happy to send you a referral list of practices who serve minors if you complete this form.

Please specify if referral source selected was "other"

Select your preferred payment/insurance

Please specify if your chosen payment was "other"

If you are wanting to use insurance to pay for services, we have providers who are in network with Aetna, Cigna, Kaiser, Lyra, Tricare and VA/TriWest. If you have a different insurance you can inquire if your insurance offers "out of network benefits" and if so, we can provide you a "Superbill" to submit to them directly.

Insurance ID Number (For Tricare folks this is your DBN 11-digit number on the back of your card, not your DOD ID)

Do you have second form of insurance other than what is listed above? (i.e. do you have a secondary insurance?)

Yes No

Type of Therapy Preferred

In person Telehealth (video counseling) Open to either

To select multiple hold down ctrl or command when making your selections

What are you seeking therapy for?

Please specify if your therapy selection was "other"

Is there a particular clinician you would like to work with?

Legal Name (If different from preferred name, required for insurance purposes)

Preferred Pronouns

What days do you prefer for appointments? (Ctrl +click to select multiple days)

What are your preferred timeframes for your appointments? (Ctrl + click to select multiple times)

Is there anything else you would like to share? Or specific scheduling requests?

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. You also agree to have someone from our team contact you by phone and/or email. *

We look forward to working with you…

Along Your Journey Towards Achieving Freedom Within.

Group/Workshop Interest

Please provide your information below and check off any groups in which you are interested in learning more about. We will reach out to you as soon as we get a set date for that particular group(s).

New Client Referral Form

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