Counseling Referral Form

* Please note that by submitting this form via this web portal, you acknowledge and accept the risk of communicating your PHI via this unencrypted system and wish to continue despite fully understanding those risks. By clicking"submit:, you agree to hold POWr, Enlightened interventions, LLC, and wix.com harmless for unintended use, disclosure, or access to this PHI.
 

*Please note that in order to process referrals, we require that you submit your insurance information. Incomplete referrals will not be processed.