New Client Counseling Referral

New Client Counseling Referral

anyone may complete this form
Who is seeking counseling?

I am seeking counseling for myself.I am seeking counseling for someone else.
What type of counseling service are you seeking?

Individual CounselingCouples or Family CounselingGroup Counseling
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?*

Referral from AGC or Solarity Counseling ClientReferral from AGC Employee or Other StakeholderReferral from Local Doctor's OfficeReferral from Local Community AgencyGoogle SearchPsychology TodayJessamine County Public School SystemAGC Print Media (e.g. flyer)Other
Personal Information

Referring Party
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Phone Number*

Area CodePhone Number
Your Relationship to Client*

MotherFatherSiblingRelativeFriendOther
Personal Information

Client
Client Name*

First NameMiddle InitialLast Name
Client Email*
example@example.com
Client Phone Number*

Area CodePhone Number
Client Date Of Birth*

MonthDayYear
Date
Client Gender*

FemaleMale
Client Language Needs
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
School or Daycare
Insurance Information
Does the client 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.
MedicAID Identification Number*
Re-enter Medicaid Identification Number*
for validation purposes
Name of Insurance Company*
Member Identification Number*
Group ID Number
if shown
Legal Guardian Information
Is the Referring Party also the Client's Legal Guardian?*

YESNO
Legal Guardian Name*

First NameLast Name
Legal Guardian Email*
example@example.com
Legal Guardian Phone Number*

Area CodePhone Number
Guardian Relationship to Client*
Is the guardian address different than the client?

YESNO
Legal Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the child in DCBS custody?*

YESNO
Placement (please select all that apply)

Lives w/ ParentsLives w/ Extended FamilyFoster CareJuvenile Detention CenterIndependent LivingCurrently HospitalizedOther
Is there a custody order/agreement for this client?

YESNO
Solarity Counseling requires a copy of the custody agreement for this client's medical chart at the time of intake.
Reason for Referral
Please tell us about your concerns and how we may help (providers, please provide the diagnosis):
Please indicate any services the client is currently receiving:

Inpatient Psychiatric HospitalizationIntensive Out-Patient TherapyCase Management ServicesMedication TherapyNoneOther
Is the referral for a follow-up to a mental health or chemical dependency hospitalization?

YESNO
Please tell us the days and times the client is available to meet for services:
Would you be interested in telehealth?

YesNoPotentially
Provider Gender Preference?

MaleFemaleNo Preference
Are you requesting a specific provider?

YESNO
Name of the Preferred Provider
Questions or Additional Information
Should be Empty:

New Client Counseling Referral

Personal Information

Personal Information

Insurance Information

Legal Guardian Information

Reason for Referral