WillThrive Referral for Vida Clinic Services
Please complete this referral form.
Contact Name (parent or guardian)
Patient's Name (must be 18 years or younger)
Patient's Date of Birth (dd/mm/yyy)
Contact Email (parent or guardian)
Contact Phone (parent or guardian)
Address Line 1
Address Line 2
District of Columbia
Language of Parent or Guardian
Language of Patient
How do you prefer to be contacted?
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.
(c)2021 The WillThrive Foundation
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.