Referral Form (HIPAA Compliant)

Referral Form (HIPAA Compliant)

Please use this form if you are an Organizational Partner, or Health Care Provider making a referral of a client to Shine a Light Counseling Center. Please note, this form utilizes special HIPAA compliant encryption on a secure server to protect Personal Health Information.
Referring Party Information
Name of Person Making the Referral

First NameLast Name
Name of the Organization Making the Referral
Email of the Person Making the Referral
example@example.com
Phone Number of the Person Making the Referral
Please enter a valid phone number.
Client Information
Name of Client

First NameLast Name
Birth Date of Client

MonthDayYear
Date
Email of Client
example@example.com
Phone Number of Client
Please enter a valid phone number.
Client's Preferred Methods of Contact

EmailTextCall
Location of Client

Street Address

Street Address Line 2

Please indicate the city or area the client lives. Shine a Light has in-person services in Santa Cruz, San Francisco, Watsonville, Scotts Valley and Monterey. We also provide telehealth services.State / Province

Postal / Zip Code
What Mornings is the Client Available for Counseling Sessions?

MonTueWedThuFriSatSun
What Early Afternoons is the Client Available for Counseling Sessions?

MonTueWedThuFriSatSun
What Later Afternoons is the Client Available for Counseling Sessions?

MonTueWedThuFriSatSun
What Evenings is the Client Available for Counseling Sessions?

MonTueWedThuFriSatSun
Services Sought
Type of Service Client is Seeking

Adult Individual TherapyTeen Individual TherapyChild Individual Therapy (5-12)Couple TherapyFamily TherapyGroup TherapyMediation
In-Person or Telehealth Preferred?

In-Person OnlyTelehealth OnlyIn-Person or Telehealth
Brief Description of the Problem(s) the Client Needs Help With
Primary Symptoms

AnxietyDepressionAngerBehavior ProblemsInfidelityDisordered EatingBody Acceptance IssuesUnemployment/Career IssuesPanicPhobiaSubstance AbuseNeurodivergenceChronic IllnessLGBTQ IdentityParentingDivorce/Co-ParentingDomestic ViolenceAutism SpectrumADHDGriefSexual IssuesRelationship ProblemAlternative RelationshipsPTSDSleep ProblemsSpiritual CrisisDelusions or HallucinationsManic StatesDisordered ThinkingCognitive ImpairmentOther
What other primary symptoms need to be addressed?
Preferred Therapeutic Approaches

Regular Talk TherapyCommunication SkillsCognitive Approaches (including CBT)Systemic ApproachesPsychodynamic ApproachesDBT (emotional regulation)Trauma-InformedEMDR or Brain-spottingSomatic-Oriented TherapyPlay TherapySand Tray TherapyDrama TherapyMindfulnessSex TherapyMediationOther
What other therapeutic approach do you suggest?
Are there any preferences for the counselor's identity?

NoYes
What preferences are there for the counselor's identity?
Payment Information
How will the client pay for services?

Client will pay out of pocketClient has insurance coverage (Medi-Cal, Medicare or Private Insurance)Referring party can be billed for the serviceVCB (Victim/Witness of Crime)Flexible Spending Account or Health Savings AccountOther
Please describe the type of payment that that will be used?
Primary Insurance Plan

Medi-Cal with no other insurance coverageMedicare (Original)Medi-Medi (Medicare and Medi-Cal)Private Insurance or Medicare AdvantagePrivate Insurance and Medi-Cal
Does the client already have VCB funding established?

YesNoNot Sure
Type of Medi-Cal Plan

Anthem Medi-CalCCAHSan Francisco Health PlanPartnership Health PlanGold Coast Health PlanLA Care - CarelonLA Care - Non-Carelon (not covered by us)Health-Net (not covered by us)Blue Shield (not covered by us)Kaiser (coverage with Authorization to see Carelon providers, coming soon)
Type of Private Insurance Plan

Anthem PPO or HMOBlue Shield PPO or EPOBlue Shield HMO or MagellanKaiser (coverage with Authorization to see Carelon providers, coming soon)Other Private Insurance (not covered by us)Aetna, Cigna, United Healthcare, Humana, TriCare, Health-Net, etc.
Type of Medicare Plan

Original Medicare (Not a Medicare Advantage Plan)Original Medicare with a Supplemental Plan F or GMedicare Advantage (Blue Shield)Medicare Advantage (Anthem)Other Medicare Advantage Plan (not covered by us)Kaiser (coverage with Authorization to see Carelon providers, coming soon)
Non-Covered Insurance Plan

The insurance plan you have indicated for the client is not one that we can bill in-network. We may be able to offer this client self-pay services on a sliding scale, which starts at $50/session. If the client is unable to afford $50/session, please refer them to an in-network provider on their insurance plan, or to the county behavioral health department. Thanks.

Out-Of-Network Benefits

If the client's insurance plan has out-of-network benefits, and the client can pay out of pocket for services, we can supply a Superbill. The client can submit this to their insurance company for reimbursement according to their plan's terms.
Non-Covered Medicare Supplemental Plan

The Medicare Supplemental plan you have indicated for the client is not one that we can bill in-network. We can bill Medicare, but we will charge the client any deductible or copayment. We can supply a Superbill that the client can submit this to their insurance company for reimbursement according to their plan's terms.
Insurance Subscriber Number (primary insurance)
Does the client have Secondary Insurance Coverage

NoMedi-Cal (Secondary to Medicare or Private Insurance)Medicare Supplemental: Plan F or Plan GMedicare (not listed above)Private Insurance (not listed above)VCBOther
Type Secondary Medi-Cal Plan

Anthem Medi-CalCCAHSan Francisco Health PlanPartnership Health PlanGold Coast Health PlanLA Care - CarelonLA Care - Non-Carelon (not covered by us)Health-Net (not covered by us)Blue Shield (not covered by us)Kaiser (coverage with Authorization to see Carelon providers, coming soon)
Type of Secondary Private Insurance Plan

Anthem PPO or HMOBlue Shield PPO or EPOBlue Shield HMO or MagellanKaiser (coverage with Authorization to see Carelon providers, coming soon)Other Private Insurance (not covered by us)Aetna, Cigna, United Healthcare, Humana, TriCare, Health-Net, etc.
Non-Covered Secondary Insurance Plan

The insurance plan you have indicated for the client is not one that we can bill in-network. We cannot see clients that have dual coverage with a policy that is out of network for us. Please refer them to an in-network provider on their insurance plan. Thanks.
Type of Secondary Medicare Plan

Original Medicare (Not a Medicare Advantage Plan)Original Medicare with a Supplemental Plan F or GMedicare Advantage (Blue Shield)Medicare Advantage (Anthem)Other Medicare Advantage Plan (not covered by us)Kaiser (coverage with Authorization to see Carelon providers, coming soon)
What Type of Secondary Medicare Supplemental Plan do you have

Anthem or Blue Shield Plan F or GSome other Insurance Company
Non-Covered Secondary Medicare Supplemental Plan

The Medicare Supplemental plan you have indicated for the client is not one that we can bill in-network. We can bill Medicare, but we will charge the client any deductible or copayment. We can supply a Superbill that the client can submit this to their insurance company for reimbursement according to their plan's terms.
Secondary Insurance Subscriber Number (or supplemental insurance)
Please upload a photo of the Front of the Primary Insurance Card

Cancelof
Please upload a photo of the Back of the Primary Insurance Card

Cancelof
Please upload a photo of the Front of the Secondary Insurance Card

Cancelof
Please upload a photo of the Back of the Secondary Insurance Card

Cancelof
Should be Empty:

Referral Form (HIPAA Compliant)

Referring Party Information

Client Information

Services Sought

Payment Information