True Living Counseling Services PLLC

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					                                                 True Living Counseling Services PLLC
                     Located at: Hillsborough Yoga & Healing Arts 1812 Becketts Ridge Dr. Hillsborough, NC 27278
                                       Telephone: (336) 327-5168             Fax: (919) 640-8683



                              REFERRAL FOR OUTPATIENT THERAPY
Referral: ___Child          ___Adult                                   Prefer to meet: ___In Office ___In Home

Insurance:_________________________________                     Insurance #:____________________________________

Referral Source:____________________________                    Referral Phone #:________________________________

Reason for
referral:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________


Child:      ___Male ___Female (check one)

Name:_______________________________________________________________________________________
              Last                                First                        Middle

Address:_____________________________________________________________________________________
               Street                       City/State/Zip                        County

Telephone #:_____________________ Ethnicity:_____________________ DOB:__________________________

School:___________________________________________ Grade:______________________________________

Parent/Guardian Name(s):________________________________________________________________________

Telephone Home#:___________________Work/Cell #:_________________ Best time to Call:________________


Adult:     ___Male ___Female (check one)

Name:________________________________________________________________________________________
              Last                                First                        Middle

Address:______________________________________________________________________________________
               Street                      City/State/Zip                         County

Telephone Home#:__________________ Work/Cell #:___________________ Best time to Call:_______________

Occupation:_____________________________ Ethnicity:_______________________ DOB:_________________

       Guardian (if applicable):_________________________ Relationship to client:_______________________

        Telephone Home#:_____________________________ Work/Cell #_______________________________

   Please complete the child or adult referral and fax the completed information along with any applicable
                                   release of information to (919) 640-8683.

				
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