Client Referral Form Template 🏥

$9.00

Referrals are great until someone emails you, “I have a client who might be a good fit,” and gives you basically no information. This customizable form gives referral partners an easy way to send you the details you actually need before figuring out next steps.

Use it for a solo or group practice, with wording options for insurance and self-pay services. You’ll have a consistent place to receive referrals without turning the referral itself into your entire intake process.

Referrals are great until someone emails you, “I have a client who might be a good fit,” and gives you basically no information. This customizable form gives referral partners an easy way to send you the details you actually need before figuring out next steps.

Use it for a solo or group practice, with wording options for insurance and self-pay services. You’ll have a consistent place to receive referrals without turning the referral itself into your entire intake process.

📎 Client Referral Forms · Google Doc
Written referral materials with insurance and self-pay options, solo and group-practice wording, therapist and service selections, and follow-up language.

💳 Insurance + Self-Pay Wording Options
Space to list accepted insurance plans, plus sample language for self-pay practices with or without superbills. Adapt the payment information to the services you actually offer.

📝 Client Referral Form · Google Form
A digital master form for professional referral sources to submit information electronically. Adapt the questions and payment sections to match your practice.

🎨 Canva Logo + Google Form Header Templates
Add your branding to the written referral materials and online form.

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Client Referral Form Template 🏥
$9.00

Referrals are great until someone emails you, “I have a client who might be a good fit,” and gives you basically no information. This customizable form gives referral partners an easy way to send you the details you actually need before figuring out next steps.

Use it for a solo or group practice, with wording options for insurance and self-pay services. You’ll have a consistent place to receive referrals without turning the referral itself into your entire intake process.