PERSONAL REFERRAL FORM FOR MENTAL HEALTH SERVICES

This referral form is for individuals looking to refer themselves or individuals under their care for services.  Please complete the form with the information for the individual being referred, whether that is for yourself or a child.   If your child is 18 years old or older, they are legally considered an adult and consent will be required from the individual in order to proceed with services.  If you are seeking family or couples counseling, please fill out the form with the information of only one member who will be attending the sessions.   If you are seeking individual counseling for multiple family members, please fill out a form for each member being referred. 
All information submitted on this referral form is completely confidential, secure and encrypted. After you submit the referral form, you will be emailed a copy for you records. 
CLIENT INFORMATION
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CLIENT CONTACT INFORMATION
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INSURANCE/PAYMENT INFORMATION
Family Solutions is In-Network with Blue Cross Blue Shield and accept Medicaid (Cardinal Innovations, Sandhills) and NC Healthchoice.  We also accept out-of-network insurances and self-pay clients.  Our rates for services are $120 for the intake appointment and $100 for each following appointment.
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PRIMARY CARE PHYSICIAN INFORMATION

CHILD/ADULT MENTAL HEALTH INFORMATION
DESIRED TREATMENT OUTCOMES: In your own words, describe the results you want for the client from receiving mental health services.
PLEASE NOTE: An excuse form will be provided for all appointments that may impact the client's work or school schedule/commitments.
Any additional information or request you'd like to provide us (Examples: therapist preferences, former history as a client with our agency, siblings in attendance with agency, specific type of therapy requested, language preferences etc.)
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Thank you for contacting us!

Thank you for your interest in Family Solutions.  We have received your referral information and our intake staff will be in contact with you shortly. 

While you are waiting for us to respond, you can go ahead an sign our online consent form.  This form can be found by clicking here.

Our intake team's goal is to respond to all referrals submissions within 2 business days.  If you haven't heard from one of our intake staff members within that time, please call us at 336-899-8800.  We want to make sure to handle your request as soon as possible.  

Family Solutions’ Intake Team

Ph: 336-899-8800

F: 336-899-8811

231 North Spring Street

Greensboro, NC 27401

 

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