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. The average wait time for a new client to be seen is 4-6 weeks. If you request a specific provider, your wait time will likely be longer. Once an opening becomes available, we will contact you. If you have questions, you can contact us at 336-283-3830 or OfficeAdmin@kernersvillecounseling.com.
Insurance

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

First NameLast Name
Guardian's Name (minor client)

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

YesNo
If the client is a minor and custody arrangements are in place, please indicate that below.
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 AETNA planI am using my PRIMARY CIGNA planI am using my PRIMARY UNITED HEALTHCARE planI am using my PRIMARY BCBS plan (NOT Blue Value or Blue Local)I am using my PRIMARY MEDICAID plan - Healthy BlueI am using my PRIMARY MEDICAID plan - PartnersI am using my PRIMARY MEDICAID plan - Trillium
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
PLEASE NOTE THAT WE HAVE LIMITED AFTERNOON APPOINTMENT TIMES AVAILABLE.

IF NEEDED, WE WILL PROVIDE A WRITTEN 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
Are you open to working with a Mental Health Counseling Intern? Our interns are master level students from local universities who are studying to become licensed counselors. Interns are supervised by a university supervisor (faculty member) and a site supervisor (licensed counselor at KCC), and they offer hour long sessions for $35.

Yes, I am open to working with an internNo, I prefer someone who is licensedNot sure, I need more information
Please mark if you are interested in any of the following group therapy options:

Adult DBT Skills Group: a classroom-like environment where adults learn ways of handling distress, regulating emotions, engaging in mindfulness, and interacting more effectively.Teen DBT Skills Group: a classroom-like environment where teens learn ways of handling distress, regulating emotions, engaging in mindfulness, and interacting more effectively.THRIVE Teen Process Group: a discussion-based environment for teens to build mutual support, self-awareness, interpersonal skills, and identity development.
All of our mental health clinicians treat common problems such as anxiety, depression, grief and loss, life transitions, and trauma. To learn about each clinician's specialty areas, review their professional biographies on the KCC website. If you are requesting a specific provider, please indicate that below:

Emily Barber, LCMHCAlisha Bisbee, LCMHCACayla Berry, LCMHCAAmelia Britt, LCMHCAVictoria Corona, LCMHCNatalie Cruthirds, LCMHCAJessy Flanery, LCMHCSAnnie Frazier, LCSWTaylor Gabbey, LCMHCShelby Gabello, LCMHCKelly Gannaway, LCMHCAGwenneth Garner, LCSWADebora Hudson, LCMHCATerence Hunt, LCMHCS, LCASMarguerite Keil, LCSW, LCASHannah Koehler, LCMHCASarah Makari, LCMHCAAlyssa Mowery, LCMHCAGenevieve Stafford, LCMHCHaleigh Yontz, LCMHCAMental Health Counseling Intern
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