Personal Referral for Mental Health Services

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, BLUE LOCAL, OR BLUE HIGH-PERFORMANCE NETWORK)
- LIMITED MEDICAID PLANS (HEALTHY BLUE, PARTNERS & TRILLIUM 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
Is the client using insurance?*

YESNO
Select one*

PRIMARY BCBS plan (NOT Blue Value or Blue Local)PRIMARY AETNA planPRIMARY CIGNA planPRIMARY UNITED planPRIMARY MEDICARE plan (limited network)PRIMARY MEDICAID plan (Healthy Blue, Partners and Trillium only)
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*
Phone Number
Please enter a valid phone number.
Upload Insurance Card - Front and Back

Cancelof
In-person or online sessions preferred?*

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

Alyssa Mowery, LCMHCAmelia Britt-Spencer, LCMHCAAnnie Frazier, LCSWCayla Berry, LCMHCEmily Barber, LCMHCGenevieve Stafford, LCMHCGwenneth Garner, LCSWAHaleigh Yontz, LCMHCAHannah Koehler, LCMHCAJessy Flanery, LCMHCSKelly Gannaway, LCMHCAMarguerite Keil, LCSW, LCASMekaila Bostic, LCMHCANatalie Cruthirds, LCMHCASarah Makari, LCMHCAShelby Gabello, LCMHCSTaylor Herring, LCMHCVictoria Corona, LCMHCMental Health Counseling Intern
Referral Source Information
Name of Referring Provider*

First NameLast 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?*

YesNo
Current Medication(s)*
Current Diagnoses*
Briefly explain the need for mental health services*
Additional Notes:
Medical Records

Cancelof
How did you hear about us?

Google searchPsychology TodayPrevious ReferralsOther Healthcare providerFriend or family memberPassed by your officeInsurance CompanyCurrent/Former Client at KCCOther
Thank you for the referral!

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

Information submitted on this form is confidential and secure.

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.

Client Information

Insurance Information

Referral Source Information

Thank you for the referral!

336-283-3830