Support Starts Here

Know someone who could benefit from our services? Please complete the referral form below.

* Required Information

Supports Form

PERSON SUBMITTING THE REFERRAL

PERSON SUBMITTING THE REFERRAL

Referring Provider / Practice Name (If Applicable)*

Contact Person

Practice Address

PHONE NUMBER

FAX NUMBER

EMAIL ADDRESS

Client Information

CLIENT INFORMATION

FULL NAME

DATE OF BIRTH

Parent / Legal Guardian's Full Name (if applicable)

Relationship to Client

Address

City

State

Zip Code

Phone Number

Alternate Phone Number

Email Address

INSURANCE INFORMATION

Belief Counseling, LLC accepts: Florida Blue, Oscar Health, United Health, Cigna, Aetna, and Self-Pay.

Insurance

Insurance ID Number

Group Number

Reason for Referral

Reason for Referral

Please briefly describe the reason for this referral

Additional Information

Attachments

Attachments

INFO:

Info: Please upload the required documents below to help us process the referral faster.

INSURANCE CARD

(Please upload a clear photo or scan of the FRONT and BACK of the insurance card.)

PHOTO ID

(Please upload a clear photo or scan of the FRONT and BACK of the photo ID.)

ADDITIONAL REFERRAL DOCUMENTS

(Attach referral forms, evaluations, authorizations, or any additional supporting documents (optional).)

Consent for Referral

Consent for Referral

Opt-In

I confirm that I have discussed this referral with the client and/or their legal guardian, and they consent to being referred to Belief Counseling, LLC for mental health counseling services.

Opt-In

I confirm that I am the client, the client's legal guardian, or an authorized individual or referring professional, and that the client and/or legal guardian is aware of and agrees to this referral to Belief Counseling, LLC for mental health counseling services

Opt-In

I understand that any personal and, when applicable, health-related information submitted through this form will be used to review and coordinate services and will be handled in accordance with applicable privacy laws and the practice's Privacy Notice and related policies.

Referring Provider Signature

Date

Support Starts Here

Supports Form

We Accept: Self Pay