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Fortitude Counseling Associates, PLLC - Referral Form- Clinician: Charessa McIntosh, MA, MSW, LCSW
"Promoting Positive Change Through Self-Empowerment"
Thank you for choosing Fortitude Counseling Associates - Charessa Mcintosh, MA, MSW, LCSW
Please visit our website at
fortitudecounselingassociates.com
for more information on our services, rates, and agency information. Please complete this referral form and submit if you are ready to request our services.
Contact us at
FCA@fortitudecounselingassociates.com
if you have any questions or concerns.
Contact Charessa McIntosh directly at
cmcintosh@fortitudecounselingassociates.com
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Email
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Your email
Referral Source Information
Date of Referral
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Name of Person Making Referral:
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Relationship to Child/Adolescent: (If Minor)
Parent
Foster Parent
Social Worker
Other:
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Name of Referring Agency or Organization (If Applicable):
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Referring Agency NPI (Medicaid Providers Only):
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Referrer Phone Number:
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Referrer Fax Number:
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Client Information
Last Name:
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Your answer
First Name:
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Your answer
Date of Birth:
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YYYY
Gender:
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Male
Female
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Phone:
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Your answer
Address:
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Your answer
Reason for Referral: (Ex: Issues with Anger, Depression, Anxiety, Issues with Relationships)
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Your answer
What outpatient services are you seeking? (Check all that apply.)
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Comprehensive Clinical Assessment
Individual Therapy/Psychotherapy
Trauma Focused CBT Assessment/TFCBT Therapy
Group Therapy
Family Therapy
Supervised Visitation
Therapeutic Supervised Visitation
Other:
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For Children/Adolescents Only
Parent/Guardian/Foster Parent Name:
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Relationship to Child/Adolescent:
Parent
Legal Guardian
Foster Parent
Other:
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Phone:
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Insurance Information:
Do You Have Insurance?
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Yes, I have insurance.
No, I will be paying in cash.
Other:
Primary Insurance Provider:
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Primary Insurance Policy Number/Subscriber ID:
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Relationship to Insured:
Self
Spouse
Child
Domestic Partner
Other:
Secondary Insurance Provider:
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Secondary Insurance Policy Number:
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Consent/Authorization
I have authorization/consent to make this referral and to share information submitted on this form with Fortitude Counseling Associates, PLLC and Charessa McIntosh, MA, MSW, LCSW for the purpose of discussing and scheduling a mental health appointment for myself or the client I am referring. If a referral needs to be made to an outside agency for services, I agree that this information can be shared with that agency for the purpose of coordination of mental health services. I have typed my name below as authorization to submitting this form. (First Name Last Name)
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