Provider Referral Form

A quick, easy and secure way to refer patients with a simple click.

Feel free to complete the brief referral form below on behalf of your patient, and I will reach out to them directly (usually the same day). Once I make contact with the patient, I will contact you to confirm their intake appointment or share if another referral was made based on the initial phone screening.

Referring Provider Information:

Referred by *Provider Name
Phone *
Fax
Provider Email Subscribe to Tom's Better-Than-Average Newsletter.
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
PCP

Patient Information:

First Name *
Last Name *
Date of Birth
Phone *
Email

Reason for Referral:

Diagnosis/ICD:
Service/Specialty Requested: *

Payment:

*
File Upload

Verification

Please enter any two digits *Example: 12
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Why I Love What I Do

Couples Counseling Makes A Big Difference

My favorite thing about being a therapist is how much of a difference I make and how quickly. Some of my most successful clients were only in need of some understanding and some education. Watching the pieces come together for lasting happiness really makes me love doing what I do.

Tom Murray, PhD–the ONLY doctoral AASECT certified Sex Therapist serving the Triad.

Dr. Tom Murray & Associates