Country Crossroads Cares Referral Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please note that, if you qualify, the adjusted fee does not apply retroactively to services rendered prior to receipt of the completed form and its accompanying documents. All paperwork submitted must be reviewed and approved before scheduling services.

Any sessions prior to approval will be the responsibility of the client.

What's the name of the client? *

Is the person a current client of CCC? *

Yes

Other:

If a CCC client, who is the counselor?

Does this person have health insurance? *

Yes

If yes to health insurance, what type?

Blue Cross Blue Shield

Tri Care

Aetna

United

Other:

Clear selection

Please describe situation. Has the person recently had a traumatic experience such as a death of family member, job loss, fire, accident, etc.? *

Is there a financial hardship that the person/family is having? Please explain if so. *

Are you requesting four 45 minute sessions with a $20 copay each session or four 30 minute sessions without a copay?

4 - 45 minute sessions with a $20 copay each session

4 - 30 minute sessions with no copay

SI Crisis Assessment

Other:

Clear selection

Any additional information?

Name of Person completing application *

Phone number of person completing application *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of countrycrossroadscounseling.com. Report Abuse

Forms