Group Referral Form
Client Name (First and Last Name)
Client Date of Birth
Client Address (Street, City, State)
Client Phone Number
Which Group is the client registering for
Anxiety Group for Teens
Emotion Management for Adults
Seeking Safety for Adults
Grief Support for Adults
It is okay for us to leave a voice mail or to text you at this number?
Okay to leave text and voice mail.
Okay to leave voicemail only.
Is the client currently seeing one of our clinicians?
If the client is a current client, which clinician are they working with.
Debra Anson, LMSW | Michigan | Colorado
Hollie Aardema, LMSW | Michigan | Florida
Jade Autumn, LMSW Pennsylvania
Rachel Boots, LMSW | Michigan
Erin Chambers, LMSW | Michigan
Daniel Cooke, LMSW | Michigan
Lindsay Collins, LMSW | Michigan
Ieeia Currie, LMSW | Michigan
Sarah Dubicki, LMSW | Michigan
Candace Gibson, LMW | Michigan
Marcia Gregory, LMSW | Michigan
Betty Sue Gurk, LCSW | Colorado
Teresa Hurtgen, LMSW | Michigan
Amy Mansfield, LMSW | Michigan
Jen Overton, LMSW | Michigan
Stephanie Sikma. LMSW | Michigan
Kelly Skrzpchak, LMSW | Michigan
Trisha Waun, LMSW | Michigan
Corey Vedin, LMSW | Michigan
Robin Wolff, LCSW | California
How did you find us?
Referral from Telebehavioral Health.US Therapist
Direct Referral from Primary Care or Another Provider
Name of person completing form if different from the client.
Relationship to Client
If this is a referral for someone, please provide a reason for referral.
Email of person completing form if different from the client.
Does the client have insurance?
Client is a current client, insurance information is already on file
Anthem Colorado - Blue Cross Blue Shield Colorado
Blue Cross Complete - Community Plan/Medicaid
Blue Cross Blue Shield PPO
Blue Cross Blue Shield Michigan
Blue Care Network
Capitol Blue | BCBS Pennsylvania
Independence BCBS Pennsylvania
Medicaid | "Straight Medicaid"
Physician's Health Plan
United Health Care
United Health Care Community Plan/Medicaid
Upper Peninsula Health Plan (UPHP)
I have a Prior Authorization from my insurance company
None - Paying Out-of-Pocket
If the client is a new client, please enter their insurance information below. If the client is a current client, skip this section.
Member ID Number (with Alpha Prefix if applicable) for the Insurance Company listed above.
Policy Holder's Name if Different From Clients
Policy Holder's Date of Birth if Different From Clients
Policy Holder's Address if Different From Client's
Do you have mental/behavioral health benefits?
If you have a deductible what is the amount of your deductible?
Has your deductible been met for this benefit year?
What is your copay?
Thank you for for submitting your appointment request a Registration Specialist will be in touch with you in the next two business days.
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