Please enable JavaScript in your browser to complete this form.
WillThrive Referral for Vida Clinic Services
Please complete this referral form.
Please enable JavaScript in your browser to complete this form.
Contact Name (parent or guardian)
*
First
Last
Patient's Name (must be 18 years or younger)
*
First
Last
Patient's Date of Birth (dd/mm/yyy)
*
Contact Email (parent or guardian)
*
Contact Phone (parent or guardian)
*
Patient's Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Language of Parent or Guardian
Language of Patient
How do you prefer to be contacted?
*
Phone Call
Text
Email
Consent for WillThrive to refer for services (Please agree to all three for a referral to be accepted)
*
By checking this box, I (contact named above), confirm to have received Authorized Consent from The WillThrive Foundation to provide Vida Clinic with the child's name and contact information (of the guardian).
I further confirm The WillThrive Foundation has agreed to recieve contact from Vida Clinic in order to initiate services.
Lastly, I agree to provide this Authorized Consent to Vida Clinic, upon request.
Submit
Are you in a crisis?
Please call the National Suicide Prevention Lifeline at 800-273-8255.
Or contact the Crisis Text Line by texting TALK to 741741.