Referrals Scholarship Pay Per Session

Counseling Referrals Form

Easily 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:

Referring Organization Information
Contact Information for Referral
Scholarship Type

Once you submit a referral we will reach out to the referral to help them get scheduled.

Use this form to refer someone from your organization to MyCounselor.Online

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.

Pay Per session -Your Organization would like to be billed per session

For referral questions, please contact michael.wall@mycounselor.online
Please choose the payment fee per session*
How many sessions 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 Form

Referring Organization

Referral Information

Scholarship Details

Counseling You Can Trust...

Credentials

Reviews

Trusted

Counseling Referrals Form

Referring Organization

Referral Information

Scholarship Details

Counseling You Can Trust...

Credentials

Evidence-Based Therapy

Reviews

Trusted