Brave Counseling & Wellness

Brave Counseling & Wellness Request an appointment

Administrative

Reason for care

1 Appointment info

2 Prescreener

Reason for care

Administrative

3 Contact information

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 ]

Phone Number

Referral Source Contact Info

Email Address

Referral Source Contact Info

Website Address:

Referral Source Contact Info

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?

Phone Call Text Message Either

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