Client Referral

Refer a client to Munier Mental Health.

This secure form allows you to refer a client for therapy services. All information is encrypted and HIPAA-compliant. Laura will review your referral and follow up within 1–2 business days.

Important Information

Response Time 1–2 business days

Confidentiality All submissions encrypted & secure

Emergency? Call 988 for crisis support

HIPAA Compliant Secure, encrypted submissions Google Workspace HIPAA BAA executed & active

Secure Referral Form

Provide client and referral details

Please complete all sections below. Fields marked with an asterisk (*) are required. Your information will never be shared with third parties.

Your Information (Referrer)

Please provide your contact details so Laura can follow up with you.

Your First Name *

Your Last Name *

Your Email *

Your Phone optional

Preferred Contact Method

Email Phone

Your Relationship to Client optional

Client Information

Provide minimal information about the client being referred to protect their privacy.

Client First Name *

Client Last Initial *

Referral Details

Please describe the reason for referral and any relevant clinical information.

Urgency Level *

Normal Urgent Crisis

Select "Crisis" only if the client is in immediate danger or experiencing a mental health emergency. For crisis situations, call 988.

Reason for Referral * 0 / 5000

Current Symptoms/Concerns optional 0 / 5000

Previous Treatment History optional 0 / 5000

Additional Notes optional 0 / 5000

Your information is encrypted and HIPAA-compliant.

Emergency Situations

If you or someone you know is in immediate danger or experiencing a mental health crisis, please do not use this form. Instead:

Call 988 for the Suicide & Crisis Lifeline (available 24/7)
Text HOME to 741741 for the Crisis Text Line
Call 911 or go to the nearest emergency room