Referral Form_Individual_R3 - SMPsychotherapy and Counseling Services

This Individual referral form is your first step. We know it’s a little long, but we need all this information to properly help you. It is designed for individuals seeking professional support in the areas of counseling, psychiatry, or psychotherapy. SMPsychotherapy & Counseling Services offers a comprehensive range of mental health services tailored to meet the unique needs of each client. By completing this form, individuals can be referred to our experienced team of licensed therapists, counselors, and psychiatrists who are dedicated to providing compassionate and effective care. The information provided will help us match clients with the most appropriate specialist to address their specific concerns and foster their mental well-being. Thank you for considering us!

Name

Date of Birth

Cell Number

Your Address

Your Town/City

Zip Code

Emergency Contact Name

Emergency Contact Phone Number:

Referring Agency/Organization:

Referring Contact Person

Their Phone Number:

Their Email Address

Relationship to Client:

In what state are you seeking services?

Reason for Referral:

Service Requested

Type of Services

Insurance Provider Information:

Policy Number:

Group Number:

Subscriber's Name (if different from client)

Subscriber's Date of Birth:

Additional Comments/Information:

Consent for Services: I consent to receive services from SMPsychotherapy & Counseling. I understand that my information will be kept confidential and will only be shared as necessary for my treatment. (if you agree - please type your full name here)