Submit Referral Request Online

Use our online form to notify our team that you would like to refer a patient. For privacy compliance, detailed patient information should be shared through our secure referral form or HIPAA-compliant email.

Referral Request

Are you referring a patient for outpatient therapy?

Yes

No – I would like to discuss partnership

Service Preference

Virtual therapy

In-person therapy

Either

Urgency Level

Routine

Priority

Urgent

"I confirm that this referral request is being submitted in accordance with applicable privacy regulations and that patient consent has been obtained where required."

How did you hear about Research Triangle Counseling?

Hospital referral network

Physician recommendation

Online search

Other