For Providers and Partner Organizations

Referral Coordination Request

Thank you for your interest in referring a client to NexGen Counseling & Consulting LLC. This form is intended for provider-to-provider referral coordination only and is used to initiate contact regarding potential referrals.

Please do not include diagnoses, risk concerns, or other protected health information in this form. Our office will follow up with the referring provider to complete the referral through a secure method.

Important: This form is not intended for urgent or emergency situations. If immediate support is needed, please contact emergency services (911) or follow your organization's established emergency protocols.