🌿 Therapy & Mental Wellness

Free Referral Source Form Template

Free referral source form for therapy practices — record how new clients heard about you and who referred them, so real channels get credit in one dashboard.

~3 min

Short by design

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Free referral source form for therapy practices — record how new clients heard about you and who referred them, so real channels get credit in one dashboard.

Disclaimer: this template is an operational starting point for therapy practices. It is not legal advice on referral relationships or advertising; review referral and consent practices against your licensing board rules.

Content note: channel options are illustrative — replace them with the sources that fit your market before use.

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About this template

Therapy practices grow mostly through word of mouth, directories and professional referrals — none of which web analytics can see. Two structured attribution questions at booking reveal where booked clients actually come from, aggregate by channel over time, and name the referring providers worth thanking. Short enough that clients answer honestly in under a minute.

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What's Included

The referrer, channel and handoff fields it captures.

Channel checklist

Search, social, word of mouth, GP, EAP and directory options.

Named referrer field

Captures professional referral relationships by name.

Timing question

Connects marketing effort to the moment clients decide to act.

Aggregated results

See which sources produce booked clients, not just clicks.

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How It Works

From copy to a logged referral in four steps.

Copy the template

Import the form into your workspace — free.

Edit the source list

Add your real channels: directories, insurers, community partners.

Ask at intake

Include the two attribution answers at booking or first contact.

Review the pattern

Filter responses monthly and double down on what works.

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Who Is This For

Who completes it — intake staff or partner clinics.

Private practice owners

Stop guessing whether ads, Psychology Today or word of mouth drives bookings.

Marketing leads

Attribute new-client growth to actual channels with named referrers.

Clinic coordinators

Keep a referral log that strengthens partner relationships.

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Key Features

What makes this referral form close the loop.

Single focused attribution question set
Named-referring-provider field for professional referrals
Optional consent line for referral follow-up
Responses aggregated in one dashboard
Filterable by source over time
1-click copy and customization

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Sample Questions Inside

A preview of the real questions — adjust channels and wording to your own practice.

How did you first hear about this practice? (search, social, friend, GP, EAP, other)
If a person or service referred you, who was it? (optional)
What made you reach out now? (open)
Which platform did you find us on? (optional)
Would you be comfortable with us thanking your referrer? (consent checkbox)
Anything that helped you choose a therapist? (open)

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Frequently Asked Questions

Do therapy practices really need a referral source question?

Yes — client acquisition for therapists is mostly word of mouth, directories and professional referral, and those are invisible in web analytics. Two intake questions reveal where bookings actually come from.

Is it awkward to ask how clients found you?

The question works better as a short written form than face to face; clients answer honestly in a checkbox list in under a minute.

Is it free to use?

Yes. Copy it into your FormLM workspace at no cost, edit the channel list to your reality and start collecting.

Can I track which referral partners send repeat clients?

Yes — named referrer answers aggregate in the dashboard, so you can see which GPs or counselors keep sending clients.

Does collecting referral info need consent?

Add the optional consent line before contacting a referrer; check your local rules on sharing that a client named their provider.

Can I merge this with my intake form?

Yes — as a standalone short form, or copy the two fields into a broader intake questionnaire.