Referral FormReferral Form

Please fill out the following information for your referral. Thank you for your referral! We will be in touch soon!

Disclaimer:
This email communication is NOT secure and we CANNOT guarantee Confidentiality. If you do not want to send an email, please call us at (864)233-5260 prompt 3 to reach a confidential voice mailbox.  This e-mail communication is intended for basic information requests and appointment requests only.  It is NOT intended for crisis situations or for the purpose of receiving counseling over the internet.  If you are in a crisis situation, please call 911 for assistance. This e-mail is checked during business hours only.  It is not checked weekends or holidays.  We will respond to your request within 24 hours of receipt during business hours. 

Your Name (required)

Your Email (required)

Telephone

Please Select Type of Referral (may choose more than one)

Subject

Your Message

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