Client Referral Form

Thank you for choosing The Village Family Service Center. We look forward to partnering with you in your patient’s care. For more information on our different programs and services, click the appropriate link below, or contact the office location that is most convenient for the client:

Outpatient Counseling
Intensive Outpatient Program for Mental Health (Fargo)
Addiction Treatment (First Step Recovery in Fargo)
In-Home Family Therapy

To make a referral: Simply fill out the form below with your client's information (if you are uncertain about any of the mandatory fields, you may enter N/A). Please include your name in the Reason for Contacting Us field. Once you've submitted this form, our Client Services Team will contact your patient to schedule an appointment with one of our providers.

First

Middle

Last

Date of Birth (if requesting services)

Parent's Name (if request is for a child)

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

OK to leave message?

Yes

Are you accessing your Village EAP Benefit?

Yes

Unsure

Where do you (or the employee with The Village EAP benefit) work?

Will you be using Health Insurance?

Yes

Unsure

Insurance Company

Reason for Contacting Us (Referring Providers: Please Include Your Name)

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