Castle Rock Referral Form

Castle Rock Family Services Referral

We provide telehealth therapy services for children, teens, adults, couples and families. We do also offer some limited in person sessions at our office in Ontario. We accept most major insurances (see list below).

You can also visit our website at: www.castlerockfamily.com

Referral Date:

Referring Persons Name:

Referring Persons Email:

Referring Agency/School:

Client's First Name

Client's Last Name

Client's or Parent (if minor) phone *

Client's or Parent (if minor) Email *

Client's Date of birth

If Minor, Parent/Guardian Name

Address

Street Address

City

State

Country

Postal code

Reasons for Referral/Identified Problem (please add any details related to checkbox items above):

Is Telehealth/Virtual therapy an appropriate options for service?

Yes

No

Maybe

Client's Insurance? (If unknown, we can reach out to the client and gather information):

Privacy Policy | Terms of Service

Consent for Service-Related Communication (Required):

By checking this box, I confirm that I have obtained consent from the client, or the client’s parent or legal guardian if the client is a minor, to submit this referral to Castle Rock Family Services. I understand and accept responsibility for ensuring this consent is valid. I also consent to receive communications related to this referral, including appointment updates, intake instructions, or other relevant service-related messages. Message frequency may vary. Message and data rates may apply. Reply HELP for assistance or STOP to opt out.

Consent for Optional Wellness & Program Updates (Optional):

By checking this box, I consent to receive occasional updates from Castle Rock Family Services regarding mental health resources, wellness events, or program offerings. I understand that this is not required for client care. Message frequency may vary. Message and data rates may apply. Reply HELP for assistance or STOP to opt out.