(retired form) PERSONAL REFERRAL FORM FOR MENTAL HEALTH SERVICES1

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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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If the client is in DSS custody or foster care, please use this section below to inform us of the current DSS social worker's contact information so that we may contact the social worker to coordinate services.  

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INSURANCE/PAYMENT INFORMATION
Family Solutions is In-Network with Blue Cross Blue Shield, most United Health Care/UMR and accept Medicaid (Vaya, Sandhills, Carolina Complete, AmeriHealth, Wellcare, Healthy Blue, and United Health Care Medicaid Plans) 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

Please indicate below if this is a request for our MATCH Program or our DBT Program. These two specialized services require additional screening and assessment to determine if you are a good fit.  Someone from our team will contact you to request additional information.   



PLEASE NOTE: An excuse form will be provided for all appointments that may impact the client's work or school schedule/commitments.

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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 as soon as we are able to. 

Our intake team's goal is to respond to all referrals submissions as fast as possible, in the order that they were submitted. Please note that our community has an extraordinary need for mental health needs. As we have availibilty, we will reach out to discuss options for scheduling. 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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