Counseling Requst Form

Referrer's Information

If you have referred this client, please provider your information.
Referrer Name

First NameLast Name
Relationship to Client
Organization or Agency (if applicable)
Referrer's Phone Number
Please enter a valid phone number.
Has the client signed a Consent to Exchange Information Form?

NoYes - WrittenYes - Verbal
If you have a written consent, please upload a copy of the consent:

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Please select the client's insurance coverage:*

Employee Assistance Program (EAP)Private InsuranceMedicaidMedicareChurch or Other OrganizationNo Insurance / Out-of-Pocket
Please provide as much information as possible so we can:

1) match you with a clinician that accepts your insurance

2) help estimate your costs
EAP Authorization Number
IMPORTANT: In order to use EAP benefits through your employer, your EAP requires you (the employee) to set up these services. Please know that we cannot schedule an appointment with you if we don't have an authorization number. Please know that your EAP will not allow us to set up EAP visits on your behalf.
Private Insurance Carrier
Private Insurance Member ID #
Group Number
Provider Services Phone Number
Please upload a copy of your insurance ID card.

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Medicaid Insurance Carrier
Medicaid Member ID #
Medicare Carrier / Plan
Medicare ID #
Church or Organization Name
Please upload an official letter on company letterhead confirming coverage of the client's counseling services.

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Please verify that you are human*
Should be Empty:

Counseling Request Form