4641 Pottsville Pike Suite 101B, Reading, PA 19605

support@emocomp.com

484-509-1038

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REFER A CLIENT

A Partner in Your Client's Care

For healthcare & community providers

Refer a Client

Thank you for referring your client to Emotional Compass LLC.

Use the form below to refer a client for outpatient therapy. The information you share helps our team review the referral, verify insurance, identify the right services, and match your client with a clinician who fits their needs and preferences.

This form is not for emergencies or situations that need immediate crisis intervention. If your client has an immediate safety concern, call 911 or have them call or text 988 (Suicide & Crisis Lifeline).

Full Name

Credentials / Title

Organization / Practice Name

Phone Number

Email Address

Provider Type

Preferred Contact Method

Email Phone Either

Would you like an update on this referral?

Yes No

First Name

Last Name

Date of Birth

Preferred Language

If other language, please specify

Phone Number

Email Address

Address

Is the client aware of this referral to Emotional Compass?

Yes No

Has the client given permission to share their information for this referral?

Yes No

Does the client plan to use insurance for therapy?

Yes No Unsure

Primary Insurance

Complete this section if the client plans to use insurance.

Insurance Company

Member / Subscriber ID

Group Number

Subscriber Name

Subscriber Date of Birth

Client's Relationship to Subscriber

Insurance Card (Front)

Insurance Card (Back)

Secondary Insurance

Does the client have secondary insurance?

Yes No Unsure

Insurance Company

Member / Subscriber ID

Group Number

Insurance Card (Front & Back)

Reason(s) for Referral

Anxiety Depression Trauma/PTSD Perinatal/Postpartum Mental Health Pregnancy After Loss Pregnancy Loss/Grief Infertility/Fertility-Related Concerns Perinatal OCD Parenting/Parent-Child Concerns Relationship/Couples Concerns Grief/Loss Life Transition Stress/Burnout Self-Esteem/Self-Worth EMDR/Trauma Treatment Other

If other, please specify

Briefly describe the reason for referral and the client's presenting concerns

Clinical Information

Does the client currently have a mental health diagnosis?

Yes No Unsure

If yes, please list the diagnosis/diagnoses

Is the client currently prescribed psychiatric medication?

Yes No Unknown

If applicable, relevant medication information

Screenings or Clinical Documentation (optional, up to 3 files)

Does the client have any current safety concerns?

No known safety concerns Yes Unsure

If yes or unsure, please provide details

Is there a history of suicidal ideation, suicide attempts, self-harm, homicidal ideation, or other significant safety concerns the receiving clinician should be aware of?

Yes No Unknown

If yes, please provide details

Does the client currently require a level of care other than routine outpatient therapy?

Yes No Unsure

If the client needs immediate evaluation, crisis intervention, hospitalization, or another higher level of care, please do not rely on this form as the only method of referral. For emergencies call 911; for a mental health crisis call or text 988.

Type of Therapy Requested

Individual Therapy Couples Therapy Family Therapy Group Therapy Other

Clinician Preferences (optional)

Preferred Service Format

Telehealth In-person Either

Preferred Days

Monday Tuesday Wednesday Thursday Friday No preference

Preferred Time of Day

Morning Afternoon Evening No preference

Referral Acknowledgment

Please confirm each statement below.

I am authorized to submit this referral and share the information included in this form.

The client is aware of this referral to Emotional Compass LLC, unless otherwise noted above.

The information provided is accurate to the best of my knowledge.

I understand that submitting this form does not guarantee acceptance for services or establish a therapist-client relationship.

I understand that Emotional Compass LLC may contact me for additional information about this referral.

Electronic Signature

Date

Not Sure Where to Start?

Take a moment to explore our services. Whether you’re looking for individual support, family counseling, or perinatal care—we’re here to help you find what fits best.

See Our Services

Support. Counseling. Real Experiences.
Your journey matters. We’re here to guide you with care and compassion.

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Our Services

Individual Therapy
Family & Couples Counseling
Perinatal Mental Health Support
Parental Leave Coaching
(RETAIN Certified)
Group Therapy

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484-509-1038

4641 Pottsville Pike Suite 101B, Reading, PA 19605

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