New Referral Form

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Our new patient referral form can be used when referring yourself or another person for therapeutic counseling services. This may include:

  • Social workers referring a child, parent, or an entire family unit
  • Clergy referring a child, adults, or family in their congregation
  • Anyone referring a child or other relative
  • Any person who is interested in receiving therapeutic counseling services

If you wish to print the form and fill it out manually, it can be:

Scanned to:
Faxed to: 302-858-4864
or Mailed to: 31 The Circle, Suite A & B, Georgetown, DE 19947

We will do our best to contact you within 48 hours of receiving your request.

For immediate assistance, we can be reached during normal business hours at 302-858-4861.

Fill out my online form.