TICN Counseling Client Referral Form
Please take the time to fill out this one page health profile so that we can place you with the most appropriate practitioner for your needs.

Thank you.

Please email us at admin@helpdeskapc.com with any questions.

Email address *
I authorize the staff of TICN/APCUT to disclose my protected health information, including but not limited to appointment times, office notes, diagnostic tests, and lab results to the practitioner whom shall receive this referral. Your name below serves as your electronic signature and acknowledgment of this HIPAA release form.
Signature Full Name *
Your answer
Gender *
Required
Date of Birth *
MM
/
DD
/
YYYY
Email Address *
Your answer
Phone *
Your answer
Mailing Address *
Your answer
Insurance Carrier *
Your answer
Insurance Plan *
Your answer
Insurance Policy Number *
Your answer
Current Medications/Dosages
Your answer
What symptoms you are currently experiencing? *
Your answer
What is your preferred method of contact once we have generated your referral: *
Thank you! You may now submit this form. You will be contacted within 48-72 business hours about your referral.
(For help with your prescriptions with a knowledgeable team of pharmacists, please contact University Pharmacy at 801-582-7624. Free delivery is available. Call to inquire).
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