Protector Overwatch Referral

Supporting those who serve and support our communities

Protector Overwatch Referral Form

Name

First

Name

Last

Date of birth

Phone Number

Street Address

City

State

Zip Code

Email Address

Preferred contact method

Do you prefer to see a male or female therapist?

Do you prefer in-person or telehealth?

What type of counseling are you seeking? (Individual, couples, or family)?

Individual

Couples

Family

Are you using Insurance, EAP, or Department Covered Sessions

Insurance

EAP

Department Covered Sessions

Insurance Type

Member ID

Group Number

Policy Holder First and Last Name

Policy Holder Date of Birth

Policy Holder’s Mailing Address (If different than client’s)

Policy Holder Relationship to Client

If you are human, leave this field blank.

If you’re freaking the
%#$@ out…

It’s totally normal to feel overwhelmed. Come as you are
and find a therapist you can vibe with.