Self-Referral Form

This referral form is for individuals looking to refer themselves or individuals under their care for outpatient counseling services. Please complete the form with the information for the individual being referred, whether that is for yourself or a child. If your child is 18 years old or older, they will need to complete this form themselves in order to proceed with services. If you are seeking family or couples counseling, please fill out the form with the information of only one person who will be attending the sessions. If you are seeking individual counseling for multiple family members, please fill out a separate form for each person.

"*" indicates required fields

Client’s Name*
Your Name (if not client)*
This is for parents and guardians completing this form.
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Client’s Address

Insurance Information

Insurance Provider*
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.
Max. file size: 32 MB.
Upload photo of your insurance card or enter information below.
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