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Do you have someone you think would be a good fit for Rebel Counseling? Fill out the form below if you are a provider or an organization looking to send someone our way

Provider/Organization Name

Provider/Organization Email

Client Preferred Start Date

MM

DD

YYYY

Client Name

First Name

Last Name

Age Range of Client?

Kiddo 0-5

Elementary (6-10)

Middle (11-14)

Highschool (14-18)

Young (Adult 19-25)

Adult (25+)

Client Insurance

Contact Name (if different than above)

First Name

Last Name

Client Contact Email

Client Phone number

Country

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###

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How would they like to be contacted?

Email

Phone

Brief Description of Referral Reason

Anything else to add?

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