Happy Place Therapeutic Services Referral From
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First Name
Last Name
Email
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Format: (000) 000-0000.
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Referral Information
Referring Provider / Practice (if applicable)
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Do you have Insurance?
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If insured, please indicate your insurance company and policy number
Upload a copy of your Drivers License, State ID or Military ID and Insurance Card for insurance verification. (Insurance must be verified as active before an appointment is scheduled)
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Please indicate what service(s) you are interested in:
Telehealth Mental Health Therapy
Therapy-Driven Weight Loss Program
Happy Place Reduced Fee Program (not eligible for Therapy Driven Weight Loss)
For Therapy Driven Weight Loss are you interested in:
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Group
Individual
One Time Deep Dive Session
Are you a participant in Curly Gainz Fitness 1:1 coaching?
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Yes
No
I am interested in learning more about 1:1 Fitness Coaching
Please include any additional information you would like us to know here. If you have a preferred provider please indicate here.
Are you requesting a specific provider?
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Latesha Adkins, LCSW
Nathalie McCall Driver, MSW Intern
Julie Gordon, MSW Intern
Monica Banks, MSW
Keauna Richmond, LMSW
No Preference
Are you open to seeing a Masters Level Intern who is under supervision of a Licensed Clinician?
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Yes
No
How did you hear about Happy Place?
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