Client Referral Form

I am interested in services for... *

Myself

Client/Consumer

Client Name *

First Name

Last Name

Client Phone *

(###)

###

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Please choose the group that best meets your/ your client's needs from the options below: *

Female Veterans

Male Veterans

Female Survivors of Sexual Trauma

Male Survivors of Sexual Trauma

LGBTQIA+

Substance Use Recovery

System Involved

Other

Below are areas of focus that are frequently addressed within art therapy groups. Please identify one or more areas of focus that would address your needs. *

Symptom Management

Stress

Anxiety

PTSD

History of Abuse

Depression

Coping Skills

Socialization

Emotional Regulation

Self-Esteem

Anger Management

Symptoms Related to Clinical Diagnosis

Increasing Self Awareness