Referral Purpose

This referral form helps CrossBridge better understand the nature of the request and determine the most appropriate next step.

Submitting a referral does not guarantee services, create a counseling relationship, or replace emergency care. CrossBridge will review the information and respond as appropriate.

Suggested Referral Form Fields

Name of Person Making Referral
Organization or Relationship to Person Being Referred
Phone Number
Email Address
Name of Person Being Referred
Age of Person Being Referred, if appropriate
Reason for Referral
Type of Support Requested
Is the Person Aware of This Referral?
Preferred Contact Method
Additional Information

Type of Support Requested

• Individual support

• Family support

• Grief support

• Trauma-informed education

• Youth or adolescent support

• Church or community support

• Workshop or presentation

• Referral guidance

• Other

Consent Note

Whenever possible, please make sure the person being referred is aware of the referral and has given permission for CrossBridge to contact them.

Emergency Notice

This referral form is not for emergencies.

If the person is in immediate danger, experiencing a crisis, or may harm themselves or someone else, please call 911, go to the nearest emergency room, or contact emergency crisis services immediately.