Therapy Referral Form

If you need to refer a patient or client for our services, you can use this form to enter their information. We will look over the form as soon as possible and reach out to the client.

The Therapeutic Studio, LLC

Counseling, Advocacy, and a

1748 Lewisburg Pike, Suite 201 & 103, Franklin, TN 37064

1325 West Main Street, Suite 108, Franklin, TN 37064

P: 615-567-3772

E: info@therapeuticstudeiollc.org

All office hours are made by appointment only

Patient Name

First Name

Last Name

Patient Date of Birth

MM

DD

YYYY

Guardian's Name (if applicable)

First Name

Last Name

Phone

(###)

###

####

Please specify what you are referring the patient for:

Free Consult for Mental Health Services

Clinical Group Therapy

Individual Clinical Therapy

Autism Evaluation

Care Coordination

Case Management

Social Skills Group

Therapeutic Respite

Please provider further details on the referral:

Patient Diagnosis

ICD

Relevant history:

Any additional comments, details, or concerns:

Therapy Referral Form

The Therapeutic Studio, LLC

Counseling, Advocacy, and Consultation