How to refer to one of our therapists:

Please complete the referral form below, but only if you have received permission from your client/patient.
You will receive a confirmation email that we have received your referral.
If you would like to fax any additional information, please send to 616-828-0293
Your referral will receive a returned email within 3 business days (from referral@theflourishingco.org)
Thank you for your referral!

I have the permission from my client/patient to complete this referral

Yes

No (if no, this form will not be processed)

Your Name

First Name

Last Name

Your Email

Name of Person being Referred

First Name

Last Name

Email (of referral)

Phone (of referral)

(###)

###

####

Address (of referral)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Dropdown

Therapist Request

Overview of Referral Request

Referrals