Counseling

Professional Referral Form

This referral form is meant to be used by medical and mental health providers and other agencies, organizations and professionals seeking to initiate outpatient counseling services for clients in their care. If you have any additional documentation you wish to share concerning a referred client, please attach to this form or email them directly to Courtney Perry at Family Services, cperry@familyservicesforsyth.org.

"*" indicates required fields

Client Information

Client’s Name*
Parent or guardian’s name if client is a minor
MM slash DD slash YYYY
Address
Insurance Information*

Family Services is In-Network with Blue Cross Blue Shield (except for the Blue Local plan), United Health Care, and accepts Medicaid (for counties within Cardinal Innovations Managed Care Organization) and NC Health Choice. We also accept out-of-network insurances and self-pay clients.

Referrer Information

Complete this section so we can contact you after the referral has been made.

Has the client been made aware that you are referring them?
Max. file size: 50 MB.



Name
Name
Name
Consent