Holistic & Multicultural Counseling Services


Please Contact Us






Patient Advocate
Quality Assurance



We serve Boston, Southeast Region and Surrounding Area

For Urgent Referral, please call the clinic directly (781) 885-7252 and ask to speak to our referral coordinator.

Non-urgent referral,  please DO NOT fill out the information below. Instead, send an email to our Referral Coordinator, REF@LAMOURClinic.org. The Coordinator will contact you within 2 to 3 business days with information regarding your appointment.

We offer flexible appointment hours including weekdays, evenings and Saturdays.

We serve Boston, Southeast, Northeast, Central, Western and Surrounding Area


Referrals-Intake Form

*Red indicates a required field


Contract Person Name:

Contract Person Phone Number:

Contract Person Email Address:

Patient’s Name:

Patient's Date of Birth:

Parent/Guardian Name:

Patient’s Address:

Patient's Best Phone:

Patient's Other Phone: (optional)

Your Program Choice(s):
You may choose more than one program.

What Kind of Referral:

What Kind of Payment:

Why is patient being referred?
What are the behavioral concerns, community support needs, mental health needs, or services needed for individual or family?


*Red indicates a required field

Important downloadable forms:

Info that needs to be faxed with referrals:
Fax: (781) 885-7256