Professional Referrals/Clinical Letters

Pastoral & Physician Referral

This is for Ministry Leaders and Medical Professionals needing to refer

patients to our Counseling Services.

Briefly tell us about the individual or family you’re referring to us. We generally respond to emails within 1-2 days.

Name*

First

Last

Phone*

Email*

Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Word Verification

Filling out this form & hitting submit verifies: Acceptance of Disclaimer/Waiver for this & ALL future ENM activities/materials. All Encouragement Now Ministries (“ENM”) classes, videos, written manuals, notes, slides, & all other information or materials (collectively, “ENM Information”) provided by ENM, its employees, agents, volunteers, & guests (“ENM Parties”) is for informational use only & is not intended as a substitute for professional counseling, advice, or care (including, without limitation, medical, psychological, financial counseling, advice, or care). Note: all clinical opinion letter requests are to be made at a client's request with the understanding that they will come at an extra fixed fee determined by ENM. Discussions with ENM Parties may be considered for discussion & personal choice options/opinions only. All personal information provided by the party signing above, on his/her own behalf, or on behalf of a minor/ward (“Attendee”), may be considered confidential if provided in a private, one-on-one setting. Discussions in a group setting are voluntary & negate any confidentiality. All ENM Information does NOT necessarily reflect the views or opinions of ENM or their staff. All ENM Information is provided to Attendees solely for the purpose of examination & at the Attendees’ own risk. ENM Parties are NOT responsible for errors or misconstruing of intended knowledge/advice in any ENM Information (e.g. An ENM staff member/counselor would never advise a client to stop using a medication without consulting a Doctor or Psychiatrist) ATTENDEE HEREBY AGREES TO INDEMNIFY, DEFEND, & HOLD HARMLESS ENM PARTIES, THEIR AFFILIATES, SUCCESSORS, OFFICERS, COUNSELORS, TEACHERS, & ASSIGNS OF ANY LIABILITY WHATSOEVER IN CONNECTION WITH THE PROVISION/USAGE OF ANY ENM INFORMATION, INCLUDING: INJURY, DAMAGE, FINANCIAL LOSS (DONATIONS GIVEN TO ENM AS A NON-PROFIT ORGANIZATION ARE NOT REFUNDABLE) OR ANY OTHER DAMAGES WHATSOEVER. Attendee understands that he/she voluntarily attended any classes/sessions with/from ENM & accepted any ENM Information freely. Attendee also accepts his/her own responsibility to use all ENM Information, provided free of charge, wisely, & at his/her sole discretion/risk. As all services are provided free of charge, ENM reserves the right to refuse service. Note, service is typically provided on a first-come-first-serve basis, we cannot guarantee that a counselor will be readily available.

I understand & accept this disclaimer*

Clinical Opinion Letters

Clinical Opinion Letters are made at a client’s request and cost.

A review of mental health/impairments can be provided by ENM

once a request is made and approved by the staff.

Briefly tell us about the purpose for needing a clinical letter and how we can best help you. We generally respond to emails within 1-2 days.

Name*

First

Last

Phone*

Email*

Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Word Verification

Filling out this form & hitting submit verifies: Acceptance of Disclaimer/Waiver for this & ALL future ENM activities/materials. Note: all clinical opinion letter requests are to be made at a client's request with the understanding that they will come at an extra fixed fee determined by ENM. All ENM Information is provided to Attendees solely for the purpose of examination & at the Attendees’ own risk. ENM Parties are NOT responsible for errors or misconstruing of intended knowledge/advice in any ENM Information. ATTENDEE HEREBY AGREES TO INDEMNIFY, DEFEND, & HOLD HARMLESS ENM PARTIES, THEIR AFFILIATES, SUCCESSORS, OFFICERS, COUNSELORS, TEACHERS, & ASSIGNS OF ANY LIABILITY WHATSOEVER IN CONNECTION WITH THE PROVISION/USAGE OF ANY ENM INFORMATION, INCLUDING: INJURY, DAMAGE, FINANCIAL LOSS (DONATIONS GIVEN TO ENM AS A NON-PROFIT ORGANIZATION ARE NOT REFUNDABLE) OR ANY OTHER DAMAGES WHATSOEVER. Attendee understands that he/she voluntarily accepted any ENM Information freely. Attendee also accepts his/her own responsibility to use all ENM Information, provided at his/her sole discretion/risk. *ENM reserves the right to refuse service.

I understand and agree with this disclaimer*