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New Client Referral
Sheet
Full Legal Name
Date of Birth
Insurance Carrier
Insurance Policy #
Insurance Group #
Full Name of Primary Insurance Card Holder
Date of Birth of Primary Insurance Card Holder
Address of Client
Phone
Email
Referring Entity/ Provider
Client Preference (Please choose one of the following in each section):
Gender
Male
Female
No Preference
Setting
In Person
Virtual
Time
Evening
Daytime
Weekends
Reason Seeking Services (Please give as much detail as possible, this helps us match you with the appropriate therapist and their skillset):
*Please attached a copy of the insurance card to this referral form.
Please send referral form to either of the following contacts:
Fax# 919-825-0119 or email: admin@keepcounsel.com
If you have any additional questions please contact the practice owner, Max Shafir, at 919- 307-8664 or email at max@keepcounsel.com.
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