Referrals Counseling SupportIf you are in need of counseling services, please fill out a referral form below. Date MM DD YYYY Person filling out form * First Name Last Name Relationship to Client * Phone * (###) ### #### Email * Referral Source * How did you hear about us? Client's Name * First Name Last Name Client's Phone * (###) ### #### Former Client? * Yes No If yes, tell us who you've previously seen Age * Sex * Male Female Other Prefer not to say Email * What city in Georgia do you live in? * What county in Georgia do you live in? * Presenting concern * If you select other, please give additional information below. Relationship Issues Anxiety/Depression Domestic Violence Sexual Assault Suicidal Ideation Bullying Apalachee School Shooting Type of Counceling * Please select all that apply. If you are seeking individual counseling for more than one person, please fill out a separate referral for EACH person. Individual Family Marriage Play Therapy In a broad sense, please describe what you are coming to counseling for * Are you comfortable seeing a therapist who may be of a different gender/ethnicity than you? * If not, please specify in the next box Yes No If you are not comfortable with having a therapist who is a different gender/ethnicity than you, please specify below. (for example, "I would prefer a female counselor") Would you prefer In Person or Telehealth services? * In Person Telehealth No preference Payment * I can self-pay I need help with payments Insurance *(see below) *Insurance The Ministry Village no longer accepts any insurance, but we have trusted partners we can refer you to. Please specify your insurance provider below. Availability (1/2) * Please select the days of the week that would work best for you for scheduling appointments. Monday Tuesday Wednesday Thursday Friday I can do any day of the week. Availability (2/2) * Please select the times of day that would work best for you for scheduling appointments. Mornings (8am-12pm) Afternoon (1pm-4pm) Evening (5pm-8pm) Any time of day works for me. Anything else you want us to know? Thank you!
