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Professional Referral Form

Answer a few questions about the client you are referring and within 24 hours Peak Resilience will send you a personalized response recommending the right counsellor for your client.

Referring Professional’s Information

Referring Client's Information

Please describe the reason you are referring your client.

(examples may include: trauma support/processing, anxiety/depression support, relationship counselling etc.):

Please describe your work with the client so far.

(examples may include: how long you've been supporting them, interventions you've used, what has helped/not helped, etc.)

What are your hopes for your client, and how do you think Peak Resilience can best support them?

When would your client be able to attend counselling?

If your client consents, would you like us to follow up with you if possible regarding their care?

If your client consents, how should we connect with your client?

How did you hear about us?

Does your client have any other funding that can supplement the fee for counselling?

You’ve reached confirmation station. Here’s a summary of your responses:

  • Referring Professional's Information
  • Referring Client's Information
  • The reason you are referring your client
  • Your work with the client so far
  • Your hopes for your client
  • When would your client be able to attend counselling
  • How would you like us to follow up with you
  • How should we connect with your client
  • How did you hear about us
  • What methods does your client have for additional funding

Thank you for your time and dedication. We’ll get moving on this right away.

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