Soul Restoration Counseling Services, PLLC : Referral & Consultation Form

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Hello,

Thank you for taking interest in Soul Restoration Counseling Services, PLLC!

To better understand your counseling needs, please complete the form below!

Once completing the form, you will be provided a link to schedule your 15 minute video consultation.

If no available appointments are listed - our office staff will be in contact with you to get you scheduled!

I am a *

potential client

professional referral source

Other:

Name of Person completing this form *

How did you hear about us? *

Client's First & Last Name *

Client's Date of Birth *

YYYY

Client's Phone Number *

Client's Email Address *

Where are you located? *

North Carolina

Virgina

Type of Service Requesting

Individual

Couples Therapy

Family Therapy

Marriage/Pre Marital Counseling

Clear selection

Client's Insurance Type ( Only accepting the following insurance types below at the moment) *

Self-Pay/Out of Network

BCBS- Blue Cross Blue Shield ( Note: We DO NOT accept Blue Value, Blue Local or Blue Home plans)

BCBS- State Health Plan

United HealthCare ( UMR/ Oxford/ Optum )

Medcost

Magellan

Aetna

Cigna

Multi-Plan

Open Path

Other:

Which therapist are you interested in for services?

( We will try our best but we can not guarantee you will be scheduled with your preferred therapist. We ask that you trust that each provider at Soul Restoration is skilled and able to assist you! )

Teneshia Webb ( Accepts only BCBS, Aetna Medcost, Open Path and Self-Pay in NC)

Roselyn McCoy (Accepts only BCBC, Medcost, Open Path and Self- Pay in NC)

Shakeria McGuire - Ratliff ( Accepts most insurances; NC and VA clients; LIMITED AVAILABILITY - WAITING LIST)

No preference

Required

Please provide a brief description of your counseling needs : *

If you decide to receive services with our practice, what days and times work best for you each week?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Early Morning

Late Morning

Early Afternoon

Late Afternoon

Evening

Submit

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