Referral & Screening Information
Welcome! Please use this CONFIDENTIAL form to tell me a little bit about you or the person you are referring...
Date *
MM
/
DD
/
YYYY
Name of person seeking therapy *
Your answer
Phone number of person seeking therapy *
Your answer
Person seeking therapy resides in North Carolina: *
Email address for person seeking therapy (emails will be secure on my end, but privacy of data cannot be 100% guaranteed in transit to you or once you receive a message from me. Providing an address is optional).
Your answer
Date of birth of person seeking therapy *
MM
/
DD
/
YYYY
What are the main concerns bringing you to therapy? *
Your answer
What days/times are ideal for appointments? *
Your answer
My practice is 100% online video or phone sessions. Are you comfortable with computers/technology? *
Your answer
Are you planning to use health insurance? If so, which provider? *
Your answer
Insurance Member ID number (check ID card)
Your answer
Are you the primary policy holder? *
Policy holder's first and last name (type "self" if you are the policy holder)
Your answer
Policy holder's date of birth (complete if you are on someone else's plan)
Your answer
Phone number for coverage/benefits (usually on the back of your insurance card. May be listed separately as "mental/behavioral health" or MH/SA).
Your answer
Have you had therapy in the past? *
Any additional information it would be helpful for me to know?
Your answer
How were you referred to me? *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of mckenziecounseling.org. Report Abuse