Make a Referral

Please complete the form below to make a referral. We will connect with you within 48 business hours about your referral. If you have any questions, please email cquick@brighterfuturescounseling.org. Thank you.

Make a Referral

Is the individual you are referring 18 or over?*
- Yes
- No
Important!!!
Unfortunately, our office is no longer providing adult therapy services. We will continue seeing children, adolescents, and families.

If you need adult, mental health, or substance abuse services, please go here.
Today's Date*
MM slash DD slash YYYY
Name of Child Being Referred*
First Last
Date of Birth*
MM slash DD slash YYYY
Guardian Name(s) and how they are related to the child*
With whom does the child reside?*
First Last
Home Address*
Street Address Address Line 2 City State ZIP Code
Phone for Guardian of the Child*
Alternate Phone for Guardian
Email for Guardian of the Child*
Will you be utilizing insurance to pay for therapy services? If yes, what insurance(s)?*
DCBS Involvement?*
- Yes
- No
Case Worker
First Last
Is there an ongoing or upcoming custody/visitation issue or court case?*
- Yes
- No
Judge's Name (Please write None if there is no Judge involved); Also, please list the names of any attorneys involved…*
Reason For Referral/Current Concerns:*
(please include any specific behavioral or emotional concerns)
Services Requested*
- Individual Therapy
- Group Therapy
- Family Therapy
- Mental Health Assessment Only
Name of Person Making Referral*
First Last
How do you know the person being referred?*
Agency Where You Work:
Phone of Person Making the Referral*
Email of Person Making the Referral*
Is Guardian aware of the referral and expecting a call?*
- Yes
- No
Will you be faxing additional information to Brighter Futures Counseling in regards to this referral? Examples: Prevention Plan/Case Plan, EPO/DVO, Court Orders, Psychological Testing Report, etc. Our fax # is: 270-982-9293*
- Yes
- No
Please upload any additional documents/information here…
Max. file size: 50 MB.

270-982-9292

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