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

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.

Website

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. This form should be forwarded 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). The client may request a specific therapist, but scheduling will be based on availability.