Referrals

Refer a client with confidence.

We welcome referrals from schools, physicians, agencies and community partners, as well as parents, family members and self-referrals. We provide services to young children, children, adolescents, adults, couples, and families.

Accepting referralsAll ages · Staten Island, NY

Who can refer

A simple, respectful referral process

Complete the form and we will reach out to the client (or their parent/guardian) to discuss services, answer questions and schedule a consultation.

Schools & school counselors

Physicians & pediatricians

Agencies & community programs

Other mental-health providers

Parents, guardians & family

Self-referrals

Privacy firstPlease share only basic contact details and a brief reason. Clinical information is discussed privately once we connect.

Consent mattersPlease make sure the client (or parent/guardian) agrees to be contacted before submitting.

Referral form

Fields marked * are required. Prefer to talk? Call (347) 938-3491.

1About you (the person making the referral)

Referral type *

Your name *

Organization & role

Your phone

Your email *

2About the person being referred

For a self-referral, simply repeat your own details.

Client name *

Age group *

Parent / guardian name (if the client is under 18)

Client (or guardian) phone *

Client (or guardian) email

Preferred contact method

Best days / times to reach

3Services requested

Individual Therapy Children & Adolescents Couples Therapy Family Therapy Group Services Anger Management Not sure

Brief reason for referral

Insurance provider (optional)

The client (or their parent/guardian) knows about this referral and has agreed to be contacted by T Moore Psychotherapy LCSW, PLLC.

I understand this form is not for emergencies. If someone is in immediate danger, I will call 911 or call/text 988.

Information is used only to contact the client about services. Clinical details are discussed privately.

What happens next

After you submit a referral

We review

Your referral is reviewed by the practice.

We reach out

We contact the client or guardian using the details provided.

Consultation

We discuss needs, questions and scheduling.

Care begins

Treatment tailored to the client’s needs and goals.

Is this an emergency?

This form is not monitored for emergencies. If someone is in immediate danger, call 911. For 24/7 mental health support, call or text 988 (Suicide & Crisis Lifeline) or go to the nearest emergency room.