Christ Church Counseling Referral Program - Strategic Counseling Solutions

Referring Pastor *

Date of referral *

Person being referred *

First

Last

Parents/Legal Guardians Name (if under 18) *

First

Last

Phone Number *

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

Is this person a member of Christ Church? *

Which office location is this person interested in? *

Number of Sessions to be covered by Christ Church *

Notes

Yes, I want to submit this form

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Name

Christ Church Counseling Program

Counseling Agreement Policy

Strategic Counseling Solutions will provide counseling for members of Christ Church at a discounted private rate of $75.00 per session. Church membership must be verified on the referral form which will be provided by the Christ Church Counseling Liason, James Mejias. James will forward the referral form to the SCS office staff, who will then contact the client and set up the initial appointment. 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). Counseling may take place on the Christ Church campus or at the SCS offices. In the event that James Mejias does not have availability for a new client, the client may be referred to another SCS therapist. The discounted private pay rate will still apply for the church member.