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Brave Counseling & Wellness

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Reason for care

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Who is completing this form today? Please write your full name below.

What is your relationship to the client?

I am the client Parent / legal guardian Spouse / partner Family member or Friend Healthcare or Mental Health Professional School or University Professional Employer / EAP Representative Other

How did you hear about Brave Counseling & Psychiatry?

Friend or Family Member Primary Care Physician or Doctor (PCP) Psychiatrist Counselor, Therapist, Psychologist or Mental Health Clinician School (teacher, counselor, staff) University / College Counseling Center EAP (Employee Assistance Program) or Employer Health Benefits Other Healthcare or Wellness Provider (Chiropractor, Massage Therapist, Dietitian) Other Professionals Google (Search, Maps, or Ads) www.Brave-MO.com (Website) Psychology Today / TherapyDen / GoodTherapy Social Media (Facebook, Instagram, LinkedIn, etc.) Other Online Search Engine Other

Referral Details: What is the Name of the individual who referred you? [ First Name, Last Name ]

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Would you like us to thank them for the referral?

Yes, you have my permission to thank them. No, thank you.

Preferred method of contact for scheduling and follow-up?

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

Brave Counseling & Psychiatry

573.825.6441 |

Columbia, MO

Main Location

601 W Nifong Blvd. Building 5A Office 5
Columbia, MO 65203-2752

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THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.