Healthcare Professional Referral

Professional Referral

If you would like to make program referral for one of your patients, please fill out this form and one of our master's level mental health professionals on staff will reach out to the person being referred.

  • Person Being Referred

  • MM slash DD slash YYYY
  • Helpful details include diagnosis specifics, if there are others in their support system that may utilize Gilda’s club program (example: youth, support person, etc), and if it is a grief referral please add their relationship to person who died.
  • Healthcare Professional Making the Referral