Internal Referring Providers

Let the client care team guide your clients to the right support and resources within Just Mind Counseling.

Internal Referral Form

Used by Just Mind staff to refer an existing or new client to another internal provider.

Referring Provider’s Name(Required)

Referring Provider's Email Address(Required)

This will be used to send you a confirmation email once the form is fully submitted successfully.

Is this an existing client or new client?(Required)

Client's Name(Required)

Client's Email Address(Required)

If this is an existing client, make sure this email address matches their email in IntakeQ.

Client's Phone Number(Required)

Client's Date of Birth(Required)

Counselor rate (if known)

Which provider is this client getting referred to? (if known)

This field is hidden when viewing the form

Will the client be using Private Pay or Insurance?

Does the client have one of our in-network insurance providers?(Required)

(EHN (Employers Health Network)/WebTPA, Aetna Health Insurance, Sana, Curative, and Harbor Health, Nomi)

Service Need (Select all that apply)(Required)

To be determined

Couples/Marital

EMDR

Family

Group

Individual

Psychological Testing

Preferred service location(Required)

Original Referral Reason

Current presenting concerns(Required)

Reason for Referral(Required)

Explain if selected "Other"

Tell us briefly about this referral:(Required)

Our Just Mind Counseling has two physical locations in Austin, TX: