Provider Referral Form

Thank you for thinking of us. Share a few details about the client you’re referring and we’ll reach out to coordinate next steps.

This form is for professional referrals and is not a secure channel for protected health information. Please share only what’s needed to make an introduction, and confirm you have the client’s consent to share their contact details.

Referring Provider

Provider name*

Please enter your name.

Practice / organization (optional)

Specialty (optional)

Email*

Please enter a valid email address.

Phone number*

Please enter a phone number.

Client Information

Client name*

Please enter the client’s name.

Client age

Parent / guardian name (if applicable)

Client email (optional)

Client phone (optional)

Reason for Referral

A brief, general description of what prompted the referral is all we need here.

Please keep this general — avoid detailed diagnoses, records, or sensitive history. This form isn’t a secure place for that; anything clinical can be shared safely once we connect.

Please share a brief reason for the referral.

Fields marked * are required. We typically respond within 1–2 business days.

Thank you for your referral

Thank you for your referral and collaboration. LexiRose Psychological Services values strong partnerships with healthcare providers, therapists, educators, attorneys, and community professionals to support individuals and families in receiving high-quality, comprehensive care. We’ve received your referral and will be in touch within 1–2 business days.

If you need to reach us sooner, call 916-304-4995.