Provider Referral Form

Please pass along this form to a client to begin working with The Dress Rehearsal for private sexuality education or coaching!

Client Details

First Name

Last Name

Phone

(###)

###

####

Date of birth

YYYY

Reason for referral

Services I'm interested in

Individual Coaching

Coaching for Partners

Group Program

Individual Education

If you selected group program, which one?

please read program descriptions on their respective pages before selecting.

Not Your Crumpled Flower

Dating While Anxious

Full-Bodied

Confidentiality

Your work with the Dress Rehearsal is confidential. However, if you would like The Dress Rehearsal to be able to communicate with your referring provider (below), you must sign a release of information with both parties. To indicate you have read this, please type, "I understand" in the field below.

Referring Provider Details

First Name

Last Name

Business/Practice Name

Provider Type