True Thao Counseling

helping individuals, couples and families

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Referral Form

We appreciate your referrals.

Please either fill out the following form and send your referral electronically or, if you prefer, download this form and fax it to
952-405-6676 upon completion.

Date

Referent's Name *

First

Last

Referent's Phone Number

Referent's Email *

Referent’s relationship to client:

Client's Name *

First

Last

Client's Date of Birth

Gender *

Female
Male
Other

Client's Address

Client's Phone Number

Can we call? *

Best time to call:

Morning
Afternoon
Evening

If the client is a minor, who has custody of the Client?

Parent or Guardian Name

First

Last

Parent or Guardian Phone

If Client is a minor, who should the provider schedule with?

Services Requested (Check all that apply): *

Diagnostic Assessment
Individual Therapy
Couples Therapy
Family Therapy
School-Based Therapy

Primary Concerns (Check all that apply): *

Acculturation and adaption issues
Aggression and Self-dysregulation
Anxiety
Depression and suicidal ideation
Domestic violence
Identity crisis
Loss and grief
Marital conflict
Oppositional Defiant Disorder
Parent-child conflict
Parenting difficulty
Physical health issues
Post-traumatic Stress Disorder
Relationship issues
self-mutilation or self-harm
Substance-induced issues
Other life concerns

Client's Primary Insurance (we do not take BCBS) *

Client's Insurance ID number

Is an interpreter needed?

Any information you think is relevant for us to know about this referral

TTCS Forms

Referral Form
Contact Form

Our Services

We provide assessment and treatment for individuals, couples and family therapy

Our Clinicians

TTCS is a mental health provider for UCare, HealthPartners, Medica, Medicaid, Medicare and Preferred One

True Thao Consulting

952-405-6038

true@truethaocounseling.com