Provider Referral Form

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This form is to be used by healthcare professionals interested in referring patients to our practice for counseling services.

Please complete this form and fax your referral information to us. We will contact your patient once this information is received. If you have any questions, you can reach our office at 864-633-7937.

Our Fax Number is 864-670-8062.

Referred By: (Name + Practice/Organization) *

Contact information for the Referrer *

Is the patient aware that you are making this referral? If not, please let them know. *

Yes

Not Yet

Required

Name of Patient being referred *

Primary reason for referral *

Please note the following guidelines about our practice: *

We work with young adults, primarily college students. {No Minors}

We operate on a self-pay or out of network basis. Super Bill available upon request.

We provide outpatient mental health services. If your patient needs intensive services or a higher level of care, we recommend the Carolina Center for Behavioral Health.

We do not provide ESA evaluations, substance abuse counseling or marriage counseling. We are unable to prescribe medications.

Required

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This form was created inside of Southern Solace Counseling.