Clinical Client Referral Form V2024

Client Referral Form

Frances Bunzl Clinical Services and Horwitz-Zusman Child & Family Center
Are you requesting services for yourself or someone else?*

SelfChildSomeone else
Please note: If you are not the parent, legal guardian, or power of attorney for the client seeking services, kindly note that the client must personally submit a request for services. Please ensure that the client returns to this form, emails us at therapy@jfcsatl.org, or contacts our Clinical Referral Line at 770-677-9474.
We appreciate your cooperation in this matter and look forward to assisting the client on their journey to well-being.
What is your relationship to the client?*

ParentGuardianship/Power of Attorney of minorGuardianship/Power of Attorney of adultSpouseCaregiverOther
Person completing this form, if other then the client*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Availability and preferences
What days and times are you generally available for services? (Please provide multiple options if possible.)*
Do you prefer in-person therapy or online/teletherapy sessions?*

In-personOnline/TeletherapyHome Visits (Older Adults Only)Other
Do you prefer in-person therapy or online/teletherapy sessions?

In-personOnline/TeletherapyHome VisitsNo preference
Do you have any preferences related to which clinician you would like to see?*
Review Clinician Bios here: https://jfcsatl.org/services/clinical-services/our-therapists
Additional information
Is there any other information you would like to share that you believe would be helpful for us to know before scheduling an initial consultation?

Private Pay
Are you interested in Private Pay fees for services?*

YesNoPotentially
Will you need a fee adjustment?*

YesNoI don't know, I want to see if I qualify.
Who will be responsible for payment?*

First NameLast Name
Total expected household income for current calendar year:*
In whole dollars
Total household income from last calendar year:*
In whole dollars
Number of family members in household supported by the income listed above:*
Please provide an explanation of your current financial situation and the need for reduced fees. Include any relevant details about unexpected expenses, changes in income, or other circumstances that have impacted your ability to afford clinical services.*
Please submit proof of income: Either W2 or Two Recent Pay Stubs

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Client Referral Form