Online Courses and CE: We offer a series of online educational programs for professionals and the public. Visit us here for previews and discounts on our online programs.

Follow PsychologySalon on Facebook: Become a fan of the PsychologySalon page; updates will appear in your news feed.

Looking for a therapist? We have eleven registered psychologists in our clinic, and we are accepting new clients. For information, visit

Friday 23 March 2012

Private Practice: The Referral Form

On Fridays for the past while, we’ve been talking about setting up a private practice: deciding whether or not to leap into the field, naming the practice, identifying the populations you wish to see, finding office space, preparing the space, identifying your referral sources, and writing a practice announcement.
Private Practice Made Simple
at the Lord Elgin Hotel, Ottawa

But do you want to provide anything along with your practice announcement? Yes! You should include a copy of your referral form. Getting referrals, after all, is the main point of sending such an announcement.

Why a referral form?

Everything about your referral form is based on a single concept:

The point of a referral form is to make sending you a referral easier, not harder.

All else flows from this. At the workshop on private practice several people have, with a slip of the tongue, referred to the form as an Application Form. This is precisely the wrong association. An application form demands that you provide information. Once we receive a bunch of forms, we will screen them and consider who to admit to the inner sanctum of our clinic.

A referral form is precisely the opposite. Its whole purpose is to make sending clients to us simple and straightforward, and to show that it isn't a test that the sender might fail.

But we don't really need one, right?

Right. You'll never require that someone use your referral form in order to refer clients to you. That would be putting a barrier between them and your service. The referral form is simply an option that the person can use if they want to make the process easier.

A referral form helps your sources remember the information they should include - like the client's phone number, gender, and diagnosis. This increases the odds that you will get the information that you like to have. When you receive the form, seeing a chicken scratch beside "Diagnosis" may help you to decipher what your source has written.

What do we do with it?

You'll send the referral form along with your practice announcement, and with occasional practice updates ("Blahblah Clinic announces that Dr Harpo Marx is joining our roster of clinicians..."). You'll also post it on your website in pdf format for free download. And you'll have a bunch of them you can send out or fax to anyone who wants one. For your great referral sources, you might even have pads of them made up by your printshop.

What should a referral form include?

Not very much! Remember, we don't want it to look difficult. Yes, it would be great if you got a complete history on every client you are sent, but this is a faint hope. Here are some bits to include:

  • A header with your complete contact information in all modes (email, phone, fax, and street address).
  • Name of client.
  • The client's gender. It's awkward asking if "Chris Lau" is home if you don't know if Chris is male or female.
  • The client's birthdate. This will signal whether you will be talking to the client or their parent.
  • Client contact information. Usually street address and phone number.
  • Reason for referral. Leave a few lines for this. Your source may just provide a diagnosis, but may want to describe a bit about the problem. The more info you get, the better.
  • Current medications, if any. This will give you hints about the person's condition and concurrent treatment.
  • White space. Many physicians use an address stamp rather than scrawling their address on every referral. Give them space to do this.

Make sure you give lots of space so that referrers don't have to squeeze their handwriting. It will be hard enough to understand as it is. And keep full size margins. If you find it hard to fit everything on a single page, you're asking for too much.

Got a sample?

Yes. In the forms accompanying Private Practice Made Simple there is a sample referral form in pdf format, here. There is also a version in Word that you can edit yourself, posted on this page.

Next Friday:  Naming your website.

*   *   *

Want more information on operating a private psychotherapy practice? 

Check out my book Private Practice Made Simple.  It contains information on starting a practice, creating a space, designing a website, getting referrals, managing finances, avoiding burnout, and much more.

The book is available at bookstores, from the Changeways Clinic website, and through Amazon here.

Vancouver Workshop November 29 2013

Click here for information and registration for the one-day workshop Private Practice Made Simple being held in Vancouver Canada Friday November 29. 


  1. I hate paperwork but I am going to use this form! Thanks for being so generous with your resources :)

  2. thanks a lot!!! It is very helpful to have such a comprehensive and professional page with information;)

  3. It is so helpful and fantastic that you are sharing these resources. I really am starting from scratch over here! Mental Health isn't really big yet in Ghana or widely accepted either, so it's great to have the resources to make it an easier process.