Counseling Referrals

Referring Organization

Who is making the referral?*

Organization Name

Contact Person at Organization Referring**

First & Last Name

Referring Contact Phone*

Referring Contact Email*

Referral Information

Who Would You Like To Refer To MyCounselor?*

First Last

Is this person a minor?*

YES
NO

Parent or Legal Guardian Name

First Last

Please provide the parent or legal guardian’s contact information below.

Their Phone*

Their Email*

Please Select Which Situation Applies*

This referral is for a staff member of our organization
This referral is NOT for a staff member of our organization

Scholarship Details

What kind of scholarship is being offered?*

No Scholarship – You would like to refer this individual to MyCounselor, but are not offering them a scholarship at this time.

Membership – Your Organization would like to scholarship a membership to MyCounselor.Online.

Pay Per Session – Billed at $126 per session.

Membership Type*

Advanced Practice = $450 every 4 weeks
Certified = $310 every 4 weeks
Resident = $252 every 4 weeks

Each subscription includes two credits per month with a counselor that corresponds with the training selected.

Number of sessions*

“How many sessions at $126 each are you approving?

Is there a fixed amount of counseling sessions you would like to apply this scholarship to?*

Yes
No

Please Indicate The Total Number of Counseling Sessions You Would Like To Apply This Scholarship Towards:*

Many of our Partners offer each referral a scholarship for 12 sessions. MyCounselor highly recommends that Organizations offer at least 8 sessions for an individual to begin their therapeutic process.

Would you like to include the $45 Set Up & Assessment Fee with your scholarship?*

Yes – Our Organization agrees to pay the Set Up & Assessment fee as a part of offering a scholarship for this referral
No – The Set Up & Assessment fee will be the referral’s responsibility

Counseling Referrals

How to Refer Your People for Counseling

With or Without a Scholarship

Organizations can refer people for counseling by filling out the referral form below.

Information Needed When Referring

Referral Form

Referring Organization

Referral Information

Scholarship Details