CONFIDENTIAL REFERRAL FORM
REFERRAL SOURCE INFORMATION
Name
*
Agency/Company
*
Email
*
example@example.com
Telephone
*
Fax
*
Patient Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Age
Sex
Address
*
City
*
State
*
Zip
*
Telephone
*
Email
*
example@example.com
INSURANCE INFORMATION
The Counseling Center is an in-network Behavioral Health Provider with the insurance plans listed in the drop down below. If your plan is not listed, you will be responsible for paying the full session fee at the time of each appointment. The ability to bill your insurance may vary by provider. If you have questions, please don't hesitate to call our office at (317) 754-0808.
Insurance Company
Please Select
Aetna
Community Health Direct (PPO/HDHP/EPO)
Community Health Direct (City of Fishers)
Central Indiana Health Partners
Encore PPO/Encore Combined
First Health/Coventry National
Galaxy Health Network
Multiplan/PHCS
Optum
Optum EAP
Sagamore Plus
SIHO
Stratose Network
United Behavioral Health (UBH)
United Medical Resources (UMR)
UnitedHealthcare
USA MCO Group Health
Group Number
ID Number
Name of Insured
Relationship to Insured
(Options include: Self, Spouse, Parent)
CLINICAL INFORMATION
Primary Diagnosis
*
Secondary Diagnosis(es)
Problem List: (CHECK ALL THAT APPLY)
Alcohol Use D/O
Anger
Suicidality
Anxiety
Amphetamine Use D/O
Grief/Loss
Chronic Relapse
Mood Instability
Relationship Conflict
Depression
Opioid Use D/O
SMI and/or Psychosis
Disordered Eating
Sedative Use D/O
Sex/Porn Addiction
Family Conflict
Self-Harm
Personality Disorder
Type of Therapy:
Individual Therapy
Couples Therapy
Family Therapy
Substance Abuse Evaluation
MAT Counseling
Other
REFERRED TO
Jason Lynch, MS, LMHC, LCAC
Morgan Albrecht, MSW, LCSW
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