Personal Referral for Mental Health Services

Personal Referral for Mental Health Services

Request an Appointment
Thank you for contacting Kernersville Counseling Center and submitting a self-referral form. Once the form is completed, you are added to our waitlist. Currently, the average wait time for a client to be seen is 4 months. If you are requesting a specific provider, your wait time will likely be longer.Once we have an opening become available, we will contact you. If you have questions in the meantime, you can contact us at OfficeAdmin@kernersvillecounseling.com.
Insurance

WE ONLY BILL PRIMARY INSURANCE POLICIES. WE ARE IN-NETWORK WITH BCBS (NOT BLUE VALUE OR BLUE LOCAL), UNITED, CIGNA, AND MEDICAID (PARTNERS AND SANDHILLS ONLY).
Client Information
Name*

First NameLast Name
Guardian's Name (minor client)

First NameLast Name
Is the client 18 years or older?*

YesNo
Date of Birth*

MonthDayYear
Date
Gender*
Client's Race/Ethnicity*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Social Security Number
Insurance Information
Do you want us to bill insurance for services?*

YESNO
Select one*

I am using my PRIMARY BCBS plan (NOT Blue Value or Blue Local)I am using my PRIMARY CIGNA planI am using my PRIMARY UNITED HEALTHCARE planI am using my PRIMARY MEDICAID plan (Partners and Sandhills only)
If we are out-of-network with your insurance carrier, we will provide a superbill (medical receipt) that you can submit to your insurance company for possible reimbursement for out-of-network benefits. Select one of the options below.*

I am NOT using insurance and DO NOT want a superbillI am NOT using insurance and DO want a superbill
Primary Insurance Co*
Policy No*
Group No*
Primary Insurance Phone No
Policy Holder's Name*

First NameLast Name
Policy Holder's Date of Birth*

MonthDayYear
Date
Policy Holder's Relationship to Client*
Upload Insurance Card - Front and Back

You may upload a picture of the front and back of your insurance card here. If you choose not to, you will need to upload it in our client portal once you are assigned to a provider.
Cancelof
Do you prefer to have sessions in-person or online?*

In-person onlyOnline onlyEither is fine
If you are requesting a specific provider, please indicate that below:

Emily Barber, LCMHCLaura Brotherton, LCMHCS, RPTVictoria Corona, LCMHCNatalie Cruthirds, Mental Health Counseling InternJessy Flanery, LCMHCSAnnie Frazier, LCSWTaylor Gabbey, LCMHCShelby Gabello, LCMHCJasmine Fulp Good, LCMHC, LCASADebora Hudson, LCMHCATerence Hunt, LCMHCS, LCASMarguerite Keil, LCSW, LCASMolly Montgomery, Mental Health Counseling InternAlyssa Mowery, LCMHCAGenevieve Stafford, LCMHC
PLEASE NOTE THAT WE HAVE LIMITED AFTERNOON APPOINTMENT TIMES AVAILABLE.

IF NEEDED, WE WILL PROVIDE AN EXCUSE FOR MISSING SCHOOL AND WORK.

HAVING A FLEXIBLE SCHEDULE IS LIKELY TO DECREASE YOUR WAIT TIME.
Select ALL days and times that work with your schedule*

MondaysTuesdaysWednesdaysThursdaysFridaysMorningsEarly afternoonsEveningsI will take any day/time availableI must have a specific day and timeOther
Primary Care Physician
NAME/PHONE NUMBER
Briefly explain the reason for seeking counseling services*
Are you having suicidal thoughts? *Please note: If you have a life-threatening emergency, call 911 or go to your nearest emergency room. Crisis resources are provided on our website, kernersvillecounseling.com.

YesNo
Are you a former KCC client?*

YesNo
Do you have an immediate family member who is currently a client at KCC?*

YesNo
Do you have a family member who is employed at KCC?*

YesNo
Anything else we should know?
How did you hear about us?

Google searchPsychology TodayHealthcare providerFriend or family memberPassed by your officeInsurance CompanyCurrent/Former Client at KCCOther
We look forward to meeting you!

Contact us if you have any questions, we are happy to help.
336-283-3830
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Personal Referral for Mental Health Services

Insurance

Client Information

Insurance Information

We look forward to meeting you!

336-283-3830