Private Therapy Referral Form

Let Go Wellness LLC · Mental-Health & Medication Management · What we think, we become.

Waterbury Office · 808 Highland Ave, Waterbury, CT 06708 · (203) 437-8193 phone/fax · letgowellness1@gmail.com · letgowelllness.com

1 · Patient / Client

Client nameDate of birthAgePhoneEmailStreet address

CityStateZIP

Guardian(s), if minor or conservateeGuardian phone

Client or guardian only: Yes, text me at this number. Let Go Wellness LLC will send appointment reminders, scheduling updates and openings from the waitlist. Usually 1–3 texts per appointment. Message frequency varies. Message and data rates may apply. Reply STOP to opt out, HELP for help. Agreeing is not required to get care. SMS Terms and Privacy Policy.

Preferred language

Referred by

Your nameOrganizationYour phone or email

Referrer email (for a thank-you, only with permission)

Client or guardian only (optional): I give written permission for Let Go Wellness LLC to tell the person who referred me only that my first visit was scheduled. No other information will be shared.

Please don't include clinical details here; our office will call for them. In a crisis, call or text 988.