The Healing Palace Client Referral Form
Client Name
First Name
Last Name
Email
Address
House name/no & street
City
State / Province
Postcode
Telephone
How does the client identify themselves?
Female
Male
Nonbinary
Other
DOB
-
Month
-
Day
Year
Name of Referer:
Referring Agency (If applicable) :
Referrer's Telephone Number
Referrer's Email
Reason for referral
Special needs to consider and/or risks identified
Issues/symptoms
Depression
Anxiety
Stress at work
General stress
Relationship difficulties
Marriage breakdown
Financial concerns
Language barriers
Loneliness
Difficulty accessing benefits
Residency issues
Family issues
Community issues
Other
Service required
Individual Therapy
Group Therapy
Youth Services
Couples/Family Counseling
Insurance
Please Select
Amerihealth Caritas
Amerigroup
Aetna
Bluecross Blue Shield
Carefirst
Cigna
D.C.Medicaid
Give an Hour
Medicare
Optum/ UBH
Private Pay
Insurance Member ID Number
Type of Appointment Preferred
Telehealth
In Person (Currently Waitlisted)
Both
Client availability
Mon
Tues
Weds
Thurs
Fri
10am-12pm
1pm-6 PM
Data protection
Client understands and accepts that their information will be kept securely until it is no longer required to assist them or by law. Permission is granted to The Healing Palace to contact the client by their identified preferred contact method.
Submit
Should be Empty: