Counseling referral form: take referrals in one tidy list

Referrals reach a counselor as a forwarded email, a call or a note on paper. Each one misses something, and you spend the first reply asking for it. I would rather give referrers one link.

Who sends referrals, and who reads them?

Doctors, school staff, HR teams and social workers send them. You read them. Self-referral is possible too, and the role question shows which is which. Browse forms for therapists.

What does it ask, and why?

The referrer's name, role and email let you reply. The person's name, age group and contact let you reach out, but only after consent. The reason, the length of time and what was tried tell you how to prepare. Urgency sorts the queue. The agreement box confirms the person knows. A second box covers a parent or guardian.

What would the referrer's AI ask?

"What is your role?" Then "What is the main reason for the referral?" Then "Does the person know about it and agree?" It shows all answers and sends only after a yes. Read about agent-fillable forms.

Is it medical advice?

No. It is a form, not medical advice, and not an emergency service. Check your local privacy rules before collecting health data. A therapy intake form is the next step after you accept a referral, and a mood tracker helps the client note progress.

Questions

Can people refer themselves?

Yes. The role question includes Referring myself. Filter the CSV on that answer if you want to treat self-referrals as their own list.

What about referrals for children?

The form asks for an age group and a box for a parent or guardian. Keep the details minimal, and confirm consent with the family yourself before any session.

How do I handle an urgent referral?

The form says it is not for emergencies. Sort the CSV by urgency_level and call urgent referrers yourself, and ask them to use a crisis line for anything immediate.

Or paste the JSON

Give this to your AI. It needs the AI Form API MCP server or an API key. It makes the form and sends you the link.

text

Create this form with the AI Form API create_form tool (or POST https://aiformapi.com/v1/forms with my API key). Then reply with the public_url.

{
  "title": "Refer someone for counseling",
  "description": "For doctors, school staff, employers and others who wish to refer someone. The person should know about the referral. This form is not for emergencies.",
  "fields": [
    {
      "id": "referrer_name",
      "label": "Your name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "referrer_role",
      "label": "Your role",
      "type": "single_choice",
      "required": true,
      "options": [
        "Doctor or nurse",
        "School staff",
        "Employer or HR",
        "Social worker",
        "Another therapist",
        "Family member",
        "Referring myself"
      ]
    },
    {
      "id": "referrer_email",
      "label": "Your email",
      "type": "email",
      "required": true
    },
    {
      "id": "referrer_phone",
      "label": "Your phone",
      "type": "phone"
    },
    {
      "id": "client_name",
      "label": "Name of the person being referred",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "client_age_group",
      "label": "Age group",
      "type": "single_choice",
      "required": true,
      "options": [
        "Child",
        "Teen",
        "Adult",
        "Older adult"
      ]
    },
    {
      "id": "client_contact",
      "label": "Phone or email for the person being referred",
      "type": "short_text",
      "max_length": 250
    },
    {
      "id": "referral_concern",
      "label": "Main reason for the referral",
      "type": "long_text",
      "required": true,
      "max_length": 2000
    },
    {
      "id": "concern_duration",
      "label": "How long has this been going on?",
      "type": "single_choice",
      "options": [
        "A few days",
        "A few weeks",
        "A few months",
        "More than a year",
        "I am not sure"
      ]
    },
    {
      "id": "urgency_level",
      "label": "How soon should they be seen?",
      "type": "single_choice",
      "required": true,
      "options": [
        "Routine",
        "Soon",
        "Urgent, please call me"
      ]
    },
    {
      "id": "support_tried",
      "label": "What has been tried already?",
      "type": "multi_choice",
      "options": [
        "A talk with the person",
        "A talk with the family",
        "School or work changes",
        "Self-help",
        "A medication review",
        "Nothing yet"
      ]
    },
    {
      "id": "support_type",
      "label": "What kind of support might fit?",
      "type": "single_choice",
      "options": [
        "One to one",
        "Couples",
        "Family",
        "Group",
        "I am not sure"
      ]
    },
    {
      "id": "client_agrees",
      "label": "The person knows about this referral and agrees to it",
      "type": "checkbox",
      "required": true
    },
    {
      "id": "guardian_agrees",
      "label": "For a child: a parent or guardian agrees",
      "type": "checkbox"
    }
  ]
}

Or call the API

bash

curl -X POST https://aiformapi.com/v1/forms \
  -H "Authorization: Bearer $AIFORMAPI_KEY" \
  -H "Content-Type: application/json" \
  -d '{"title":"Refer someone for counseling","description":"For doctors, school staff, employers and others who wish to refer someone. The person should know about the referral. This form is not for emergencies.","fields":[{"id":"referrer_name","label":"Your name","type":"short_text","required":true,"max_length":150},{"id":"referrer_role","label":"Your role","type":"single_choice","required":true,"options":["Doctor or nurse","School staff","Employer or HR","Social worker","Another therapist","Family member","Referring myself"]},{"id":"referrer_email","label":"Your email","type":"email","required":true},{"id":"referrer_phone","label":"Your phone","type":"phone"},{"id":"client_name","label":"Name of the person being referred","type":"short_text","required":true,"max_length":150},{"id":"client_age_group","label":"Age group","type":"single_choice","required":true,"options":["Child","Teen","Adult","Older adult"]},{"id":"client_contact","label":"Phone or email for the person being referred","type":"short_text","max_length":250},{"id":"referral_concern","label":"Main reason for the referral","type":"long_text","required":true,"max_length":2000},{"id":"concern_duration","label":"How long has this been going on?","type":"single_choice","options":["A few days","A few weeks","A few months","More than a year","I am not sure"]},{"id":"urgency_level","label":"How soon should they be seen?","type":"single_choice","required":true,"options":["Routine","Soon","Urgent, please call me"]},{"id":"support_tried","label":"What has been tried already?","type":"multi_choice","options":["A talk with the person","A talk with the family","School or work changes","Self-help","A medication review","Nothing yet"]},{"id":"support_type","label":"What kind of support might fit?","type":"single_choice","options":["One to one","Couples","Family","Group","I am not sure"]},{"id":"client_agrees","label":"The person knows about this referral and agrees to it","type":"checkbox","required":true},{"id":"guardian_agrees","label":"For a child: a parent or guardian agrees","type":"checkbox"}]}'

JSON definition

json

{
  "title": "Refer someone for counseling",
  "description": "For doctors, school staff, employers and others who wish to refer someone. The person should know about the referral. This form is not for emergencies.",
  "fields": [
    {
      "id": "referrer_name",
      "label": "Your name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "referrer_role",
      "label": "Your role",
      "type": "single_choice",
      "required": true,
      "options": [
        "Doctor or nurse",
        "School staff",
        "Employer or HR",
        "Social worker",
        "Another therapist",
        "Family member",
        "Referring myself"
      ]
    },
    {
      "id": "referrer_email",
      "label": "Your email",
      "type": "email",
      "required": true
    },
    {
      "id": "referrer_phone",
      "label": "Your phone",
      "type": "phone"
    },
    {
      "id": "client_name",
      "label": "Name of the person being referred",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "client_age_group",
      "label": "Age group",
      "type": "single_choice",
      "required": true,
      "options": [
        "Child",
        "Teen",
        "Adult",
        "Older adult"
      ]
    },
    {
      "id": "client_contact",
      "label": "Phone or email for the person being referred",
      "type": "short_text",
      "max_length": 250
    },
    {
      "id": "referral_concern",
      "label": "Main reason for the referral",
      "type": "long_text",
      "required": true,
      "max_length": 2000
    },
    {
      "id": "concern_duration",
      "label": "How long has this been going on?",
      "type": "single_choice",
      "options": [
        "A few days",
        "A few weeks",
        "A few months",
        "More than a year",
        "I am not sure"
      ]
    },
    {
      "id": "urgency_level",
      "label": "How soon should they be seen?",
      "type": "single_choice",
      "required": true,
      "options": [
        "Routine",
        "Soon",
        "Urgent, please call me"
      ]
    },
    {
      "id": "support_tried",
      "label": "What has been tried already?",
      "type": "multi_choice",
      "options": [
        "A talk with the person",
        "A talk with the family",
        "School or work changes",
        "Self-help",
        "A medication review",
        "Nothing yet"
      ]
    },
    {
      "id": "support_type",
      "label": "What kind of support might fit?",
      "type": "single_choice",
      "options": [
        "One to one",
        "Couples",
        "Family",
        "Group",
        "I am not sure"
      ]
    },
    {
      "id": "client_agrees",
      "label": "The person knows about this referral and agrees to it",
      "type": "checkbox",
      "required": true
    },
    {
      "id": "guardian_agrees",
      "label": "For a child: a parent or guardian agrees",
      "type": "checkbox"
    }
  ]
}

A counseling referral form that asks for the right things