Church Referrals - Strategic Counseling Solutions

Please fill out this form if you are being referred to Counseling from Christ Church or Cedar Crest Baptist Church. Our office staff will call you to to discuss scheduling.

Strategic Counseling Solutions will provide counseling for members of Christ Church and Cedar Crest Baptist Church at a discounted private rate of $75.00 per session. If the church member would like to use their private insurance, SCS office staff will verify the member’s benefits and inform them of their estimated cost (co-pay, co-insurance, or deductible amount).

Name of person filling out this form

Name of church and referring Pastor *

Date of referral *

Name of person being referred to counseling *

First

Last

Parents/Legal Guardians (if under 18) *

First

Last

Phone Number to call for scheduling *

Do we have permission to leave a message at this number? *

Is this person a member of the referring church *

Which office location is this person interested in? *

Reason for referral for counseling

Yes, I want to submit this form

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.