Refer A Client Form | Bridge To Wellness Foundation

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Our Mission
Impact
Partners
Contact

DONATE

Full Name*

Phone Number

Your email

Client Name*

Client Contact [Please include here the best way to contact the client being reffered]*

Does the person you're referring currently have access to a device for online sessions?

Yes, a Laptop/Computer

Yes, a Cell Phone

Not Sure

Does the person you're referring currently have access to internet/Wi-Fi for online sessions?

Yes

Sometimes

Not Sure

Does the person you're referring have access to a private space for online sessions?

Yes

Sometimes

Not Sure

Does the person you're referring need help figuring out access to a device, internet, or private space?

Yes

Maybe

Not Sure

Is there anything else we should know about the person you’re referring so we can help them receive the best care?

“I understand that submitting this form gives Bridge to Wellness Foundation permission to contact me about counseling services and next steps.”*

I understand

“I understand this form is not a crisis service and should not be used for emergencies.”*

I understand

Referring a client to free online counseling?

Bridge to Wellness Foundation helps cover the cost of online counseling sessions for people who may not otherwise have access to mental health support. Fill out this short form, and someone from our team will follow up with next steps.

Important note: This form is not for emergencies. If someone you know is in immediate danger or experiencing a crisis, please call 911 or 988 for immediate support.