Referral Form

This form should be used by community partners only. To initiate services for yourself or your child please complete the Online Consultation Form.

We will contact the individual referred within 48 hours. If this is an emergency, please contact 988 or refer the individual to their local emergency services.

For further questions please email: bknox@renewedresilience.org

Referral Source

What agency are you associated with?

Person Making Referral

First Name

Last Name

Phone

(###)

###

####

Would you like for us to keep in touch regarding initial contact with the referred?

Yes

Is the person being referred a minor?

Yes

Parent/Guardian Name (if under 18)

First Name

Last Name

Parent/Guardian Email

Parent/Guardian Phone

(###)

###

####

Person Being Referred

First Name

Last Name

Phone

(###)

###

####

I have informed the referred that Renewed Resilience is currently an online practice. They are ok with receiving online therapy at the moment.

Yes

Reason for Referral

Renewed Resilience, PLLC is an online private practice based in Charlotte, NC.

We are a growing team of trauma specialists providing trauma therapy and EMDR to clients across the states of North Carolina and Virginia via telehealth.

Referral Form

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