De-identified by design — most referrals take under a minute.
What brings the patient in? Select 1–3 — prioritizing keeps the card scannable.
Anxiety & OCD-spectrum
Mood
Trauma & Stress
Eating & Body
Neurodevelopmental & Cognitive
Behavioral & Impulse
Relational & Family
Other
Not listed?
What kind of care is the patient looking for?
Optional — the kind of provider being sought.
Never an exact age or DOB — age group only.
Picklist only — this field can never hold a street address.
What can the patient use? Payment mismatch is the #1 reason referrals die.
Which carriers does the patient hold?
e.g. "client can pay no more than $100/session"
Optional. The only typing in the form — keep it about the clinical picture.
Describe the clinical picture, not the person. No names, initials, birthdates, contact info, schools, or employers — even in a private network. Good example: “College-age pt with contamination OCD, 2 prior courses of talk therapy, needs a provider experienced with ERP.”
Every referral lives in at least one of your networks.
4required fields leftPresenting concern · Seeking · Age group · …