Enroll as a Business or Church Sponsor
This form is required for EACH individual you wish to sponsor.
Organization Name:
*
Your Name (Must be an Authorized Representative)
*
First Name
Last Name
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Name (the employee or organization member you are referring)
*
First Name
Last Name
Patient's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Has the patient been informed of your intention to sponsor professional counseling services? If no, the organization must inform and acknowledge acceptance from patient prior to completing this form.
*
Yes
No
Fee schedule
Fee is $90 per 1 hour session.
How many 1-hour sessions would you like to sponsor for the patient?
*
Unlimited. Continue therapy as often and for as long as needed.
4 sessions
8 sessions
12 sessions
Payment method:
*
Organization's Credit/Debit Card. Charged per session.
Organization's Credit/Debit Card. Charged in intervals of 4 session.
Organization's Credit/Debit Card. Prepaid for total number of sessions.
Cash / Check (due at the time of service, or prior to service)
Additional information:
Next steps:
Our Patient Coordinator will call you to verify information and collect payment over the phone. If you do not receive a call within 2 business days, please contact 843-894-0000. Please note, organizations do not have authorization or access to electronic health records of the patient, regardless of payor.
Type a question
*
Please verify that you are human
*
Submit
Should be Empty: