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Home
About
Our Team
Services
Veterans and First Responders
What to Expect
Contact Us

Start Your Healing Journey Today

Reach out today to begin compassionate, personalized mental health support with our experienced team.

Connect With Our Counselors

3293 Harrison Blvd., Ste. 200
Ogden, UT 84403

(801) 380-7322
info@dorsettcounseling.com

Mon, Wed & Fri: 9:00 AM – 5:00 PM
Tue & Thu: 9:00 AM – 6:00 PM
Sat & Sun: Closed
If you are experiencing a mental health emergency, please download the SafeUT app or dial 988 to talk to a mental health professional.

Please select the option below that matches your inquiry type.

We look forward to hearing from you!

I am seeking therapy for myself or a loved one

Step 1 of 5 - Referrer Contact Information

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Referrer Contact Information

Name of Organization(Required)

Referrer's Full Name(Required)

First Last

Phone Number(Required)

Email(Required)

Fax

Client Contact Information

Is the individual receiving services a minor?(Required)

Yes

No

Legal Guardian's Full Name(Required)

First Last

Legal Guardian's Preferred Name

If the name they go by is different from their legal name

Legal Guardian's Phone Number(Required)

Legal Guardian's Email(Required)

Client's Full Name(Required)

First Last

Client's Preferred Name

If the name they go by is different than legal name

Client's Date of Birth(Required)

Month

Day

Year

Client's Gender

optional

Client's Phone Number(Required)

Client's Email(Required)

Client's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reason for Care

What is the main reason for seeking care?(Required)

ADHD

Anger Management

Anxiety & Panic Disorders

Autism Spectrum Disorder

Behavioral Issues

Caregiver/Parent Support

Chronic Illness & Chronic Pain

Depression & Mood Disorders

Divorce

Grief & Loss

Life Transition

Psychosis

Relationship Issues

Self Harm

Trauma & PTSD

Other

Other reason(Required)

Other reason

What kind of services are being sought?(Required)

Psychotherapy

Neurofeedback

Support Group

Not Sure

What mental health concerns or treatment have occurred?

In therapy now

In therapy in the past

Taking psychiatric medication now

Taken psychiatric medication in the past

Hospitalized for mental health reasons now or recently

Hospitalized for mental health reasons in the past

In inpatient or rehab program now or recently

In inpatient or rehab programs in the past

Known neurological or genetic disorder

Attempted suicide in the past

Additional Notes

Please include any other relevant information, e.g. medical history, more about their current situation, recommended treatment or area of focus, accessibility or support needs, any needs for ongoing coordination of care, etc.

Billing and Payment

Payment Method(Required)

How does the client plan to pay?

Insurance Details (if applicable)

Following Up

Would you like us to contact the client to schedule a consultation and/or first appointment?(Required)

Yes, go ahead and schedule directly with the client.

No, please contact the referrer to discuss remaining questions and concerns.

Any other questions or concerns we can help with?

Δ

I am a healthcare provider submitting a referral

3293 Harrison Blvd., Ste. 200
Ogden, UT 84403
(801) 380-7322
info@dorsett-counseling.com

Mon, Wed & Fri: 9:00 AM – 5:00 PM
Tue & Thu: 9:00 AM – 6:00 PM
Sat & Sun: Closed

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If you are experiencing a mental health emergency, please download the SafeUT app or dial 988 to talk to a mental health professional.

Home
About
Our Team
Services

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