New Client Referral Form
Alabaster Counseling
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I need help with...(Presenting problem) *
We offer both virtual and in person sessions. Which would you prefer? *
How did you hear about us?
*
Client Information
First and Last Name *
Date of Birth *
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DD
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Phone Number *
Email Address *
Street Address *
CITY/STATE/ZIP *
Insurance Carrier *
If Medicaid, please list your specific plan:
Member Identification # *
Group Identification #
Insurance Carrier’s Phone #
Primary Insurance Holders Full Name 
If different from client
Primary Insurance Holders Date of Birth
If different from client
MM
/
DD
/
YYYY
Primary Insurance Holders Street Address/City/State/Zip
If different from client
Primary Insurance Holders Relationship to Client *
Has the primary insurance deductible been met? *
Primary Insurance Deductible Amount $
Do you have another insurance plan? *
Secondary Insurance Holders Full Name
Secondary Insurance Holders Date of Birth
MM
/
DD
/
YYYY
Secondary Insurance Holders Street Address/City/State/Zip
Relationship to Client
Clear selection
Secondary Insurance Carrier
Secondary Insurance Member Identification #
Secondary Group Identification #
Secondary Insurance Carrier’s Phone #
Complete this section only if client is under the age of 18:
Legal Guardian Full Name
 Legal Guardian Street Address/City/State/Zip
Legal Guardian Email
Legal Guardian Phone Number
If you are experiencing a mental health crisis, to include but not limited to, having thoughts of harming yourself or others, or any other medical emergency, please call 911 or go to your nearest emergency room.
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This form was created inside of Alabaster Counseling.