Palm Atlantic Behavioral Health - Professional Referral Step 1 of 3: Referrer Information → Step 2: Client Information → Step 3: Referral Details Referrer NamePlease enter the referrer name. Organization / Practice Role/Title Phone NumberPlease enter a valid phone number. Email AddressPlease enter a valid email. Preferred Contact Method Phone Email Relationship to Client Client Full NamePlease enter the client's name. Date of BirthPlease enter the date of birth. Client Phone Client Email Address (City, State, ZIP) Parent/Guardian (if minor) Parent/Guardian Phone & Email Insurance Coverage (if any) Insurance covers therapy services. Coaching services are private-pay. Superbills are provided for out-of-network PPOs. Best Time to Contact Client Morning Afternoon Evening Reason for ReferralPlease describe the reason for referral. Services Requested Individual Therapy Couples Therapy Family Therapy ADHD & Neurodivergent Coaching Executive Function Coaching Trauma/PTSD Counseling Urgency of Referral Routine Moderate Concern Urgent Additional Notes / Comments Supporting Documents (optional)You may upload treatment summaries or relevant reports. (Max 10 MB total; PDF/DOC/PNG/JPG) I confirm that I have obtained the client’s consent to share this information with Palm Atlantic Behavioral Health for the purpose of initiating services.Do not submit emergencies via this form. If this is an emergency, call 911 or go to the nearest emergency room.Consent is required to proceed. Back Next Submit Referral
