Referrals

If this is a medical emergency, please call 911. This form is not monitored in real time.

Use this form to refer a client to Kind Path Guide. Everything you share is treated with care and confidentiality.

When you submit, your email program opens with the referral details filled in, addressed to Kind Path Guide. Review it and press send from your own account. Fields marked * are required.

1Referring organization

Organization name * Please enter your organization name.

2Referring staff contact

Your name * Please enter your name.

Your role or title

Your email * Please enter a valid email address.

Your phone * Please enter a phone number.

3Client

Client name * Please enter the client's name.

Best way to reach the client * Phone, email, address, or a note such as "contact through daughter." Include the best times if you know them. Please tell us how to reach the client.

Client ZIP code * Helps us confirm the client is within our service area. Please enter a valid ZIP code.

4Situation and urgency

Urgency *Please select an urgency level.

Describe the situation * Please describe the situation.

5Known supports

Who is already part of this client's circle of support?

Check all that apply. For each one, add a name and contact number if you have them.

Your referral email is ready

Your email program should have opened with the referral details filled in. Please review and press send from your own account so we have your reply address.

If nothing opened, use the button below and we will follow up with you.