Professional Referral for Mental Health Services
Thank you for choosing KCC
Information submitted on this form is confidential and secure.
Thank you for contacting Kernersville Counseling Center and submitting a referral form. Once the form is completed, the individual being referred is added to our waitlist. Currently, the average wait time for a client to be seen is 3 months. If you are requesting a specific provider, the wait time will likely be longer.
Once we have an opening become available, we will contact the client. Once the client is seen at KCC, their provider will contact you. If you have questions in the meantime, you can contact Amy Stewart at OfficeAdmin@kernersvillecounseling.com.
WE ARE IN-NETWORK WITH:
AETNA
CIGNA
UNITED
BCBS (NOT BLUE VALUE OR BLUE LOCAL)
LIMITED MEDICAID PLANS (HEALTHY BLUE, PARTNERS & SANDHILLS ONLY)
Client Information
Name
*
First Name
Last Name
Guardian's Name (minor client)
First Name
Last Name
Is the client 18 years or older?
*
Yes
No
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
Other
Prefer not to say
Client's Race/Ethnicity
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
Social Security Number
Insurance Information
Is the client using insurance?
*
YES
NO
Select one
*
PRIMARY BCBS plan (NOT Blue Value or Blue Local)
PRIMARY AETNA plan
PRIMARY CIGNA plan
PRIMARY UNITED plan
PRIMARY MEDICARE plan (limited network)
PRIMARY MEDICAID plan (Partners and Sandhills only)
Primary Insurance Co
*
Policy No
*
Group No
*
Primary Insurance Phone No
Policy Holder's Name
*
First Name
Last Name
Policy Holder's Date of Birth
*
-
Month
-
Day
Year
Date
Policy Holder's Relationship to Client
*
Upload Insurance Card - Front and Back
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In-person or online sessions preferred?
*
In-person only
Online only
Either is fine
Unknown
If you are requesting a specific provider, please indicate that below:
Emily Barber, LCMHC
Alisha Bisbee, LCMHCA
Cayla Berry, LCMHCA
Victoria Corona, LCMHC
Natalie Cruthirds, LCMHCA
Jessy Flanery, LCMHCS
Annie Frazier, LCSW
Taylor Gabbey, LCMHC
Shelby Gabello, LCMHC
Kelly Gannaway, LCMHCA
Debora Hudson, LCMHCA
Terence Hunt, LCMHCS, LCAS
Marguerite Keil, LCSW, LCAS
Alyssa Mowery, LCMHCA
Genevieve Stafford, LCMHC
Mental Health Counseling Intern
Hannah Koehler, LCMHCA
Gwenneth Garner, LCSWA
Amelia Britt, LCMHCA
Referral Source Information
Name of Referring Provider
*
First Name
Last Name
Business Name
*
Phone Number
*
Please enter a valid phone number.
Fax Number
*
Please enter a valid phone number.
Email
*
example@example.com
Is the client (or guardian) aware that a referral is being made?
*
Yes
No
Current Medication(s)
*
Current Diagnoses
*
Briefly explain the need for mental health services
*
Additional Notes:
Medical Records
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How did you hear about us?
Google search
Psychology Today
Previous Referrals
Other Healthcare provider
Friend or family member
Passed by your office
Insurance Company
Current/Former Client at KCC
Other
Thank you for the referral!
Contact us if you have any questions, we are happy to help.
336-283-3830
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