New Client Counseling Referral

New Client Counseling Referral

anyone may complete this form
Date

MonthDayYear
Who is seeking counseling?

MeSomeone Else
What type of counseling service are you seeking?

Individual CounselingCouples or Family CounselingGroup CounselingTargeted Case ManagementCommunity SupportSŌLr Sessions
Is the client needing services over the age of eighteen (18)?

YESNO
Is the client needing services an All God's Children foster child?

YESNO
How did you hear about Solarity Counseling?*

Facebook/InstagramAGC or Solarity Counseling ClientAGC Employee or Other StakeholderPartners HealthcareLocal Doctor's OfficeLocal Church / Community AgencyGoogle SearchPsychology TodayFindHelpNow.comJessamine County Public School SystemAGC Print Media (e.g. flyer)
What Doctor's office made you aware of Solarity Counseling? *
What church or community agency made you aware of Solarity Counseling? *
Personal Information

Referring Party
Your Name*
please provide full name
Your Email*
example@example.com
Your Phone Number*

Area CodePhone Number
Your Relationship to Client*

MotherFatherSiblingRelativeFriendOther
Personal Information

Client
Client Name*
please provide full name
Client Email*
example@example.com
Client Phone Number*

Area CodePhone Number
Client Date Of Birth*

MonthDayYear
Date
Client Gender*

FemaleMale
Client Language Needs
School or Daycare
Insurance Information
Does the client have some form of insurance?*

YESNO
Do you understand that, without insurance, you will be considered a "Self Pay" client and required to pay the full rate of $120.00 for a one (1) hour session at the time of service?*

YES - I understand that I will be a self pay client.NO - I need more time to think about this decision.
Client's insurance carrier type?*

Medicaid CarrierCommerical CarrierBoth
We understand the need to think about whether you can handle this out-of-pocket expense in your family budget. Occassionally, we have gracious donors that desire to underwrite a portion of the counseling expenses for those that are uninsured and do not, currently, have the means to cover the full, self pay cost of their treatment.

If you have time, reach out to our Treatment Director, Kimberly Moynahan, to see if any such provisions are currently available.

She can be reached at 859.881.5010 ext. 120 or kmoynahan@kyagc.org.

We hope to hear from you soon.
Name of Insurance Company*
Member Identification Number*
Group ID Number
if shown
Medicaid ID Number*
Re-enter Medicaid Identification Number*
for validation purposes
Legal Guardian Information
Is the Referring Party also the Client's Legal Guardian?*

YESNO
Legal Guardian Name*
please provide full name
Legal Guardian Email*
example@example.com
Legal Guardian Phone Number*

Area CodePhone Number
Guardian Relationship to Client*
Is the child in DCBS custody?*

YESNO
DCBS Worker*
DCBS Worker Email*
example@example.com
County*
DCBS Worker Phone

Area CodePhone Number
Reason for Referral
Please tell us about your concerns and how we may help (providers, please provide the diagnosis):*
Is the referral for a follow-up to a mental health or chemical dependency hospitalization?*

YESNO
Preferred Availability: DAYS (choose all that apply)*

MondaysTuesdaysWednesdaysThursdaysFridaysWeekend
Preferred Availability: TIME (choose all that apply)*

MorningsAfternoonsEvenings
Would you be interested in telehealth?*

YesNoPotentially
Are you requesting a specific provider?*

YESNO
Name of the Preferred Provider*
Should be Empty:

New Client Counseling Referral

Personal Information

Personal Information

Insurance Information

Legal Guardian Information

Reason for Referral