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Referral Form
 This referral form is meant to be used by medical and mental health providers and other agencies, organizations and professionals seeking to initiate outpatient services for clients in their care. If you are requesting to schedule a session for yourself do not complete this form, click the tab at the website that says schedule your session. If you have consent from the consumer you may also schedule their appointment by selecting the schedule your session tab.
All information submitted on this referral form is completely confidential, secure and encrypted.
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Email *
Parents of adult children CANNOT initiate treatment on their adult child's behave due to CONFIDENTIALITY and HIPPA regulations. If you would like your adult child to engage in counseling then you will need to give them our information in order to have them initiate treatment.  We will not follow up with referrals made if this is the case. *
We do not offer pre consultations or consultations? *
Referral Source: Name of the Organization, person making the referral and contact number. *
Do you have an active consent for release of information? *
Please complete the patient's information
First name: *
Last name *
Date of Birth *
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Home Address: (Please put the address that is on the insurance card) *
City *
State *
zip code *
Phone number *
Patients: email address *
Medication List *
How did you hear about the practice? *
Reason for seeking services? *
Insurance Information or EAP. Who is their insurance carrier or EAP carrier? *
Have you contacted your insurance to verify treatment is covered *
If you have not done so already please stop and contact your insurance provider. You need to verify that your session is covered, what your deductible is and what your copay is. You can find the number on the back of your insurance card. *
Required
What questions should I ask my insurance provider? *
If you are using your EAP benefit, you must have contacted your EAP provider and let them know you have selected provider: Samaria M Colbert or Kingdom Creative Counseling PLLC. Otherwise, you may have an unexpected out of pocket fee because you have not gotten authorization from your EAP provider BEFORE your session. *
Required
Have you gotten authorized from your EAP to see Samaria M Colbert MSW LCSW or Kingdom Creative Counseling PLLC *
Required
Did your EAP give you an authorization number? *
Subscribers name: *
Policy Number: *
Do you have a deductible? *
What is your deductible?
Name of secondary insurance
Policy number for the secondary insurance
Emergency contact person (Name) *
Emergency contact person (Phone Number) *
I understand that if I am paying for my session out of pocket the session must be paid in full BEFORE my first session or my session will be canceled. You will be sent a invoice within 24 to 48 hours prior to your scheduled session. *
Emergency contact phone number *
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Samaria M Colbert. I understand that I am financially responsible for any balance. I also authorize Kingdom Creative Counseling PLLC or Samaria M Colbert to release any information required to process my claims. By clicking on this form you are essentially authorizing us to bill your insurance. Checking in the box is, in essence, the equivalent to your signature. *
Name: *
*
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Signature *
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