New Client Referral

Referral Source

Referral Phone #

Date

How did you hear about us?

Intake Rep

Ibby (ibby@silverliningsnc.com)
Amanda (amanda@)silverliningsnc.com)
Ph: 919-371-4381 / Fax: 919-300-7943

Client Information (as it appears on Insurance Card)

Name

DOB

Gender
Male Female

Street Address

City

State

Zip

Contact Phone

Community

Alternative Phone

Email

Client to be seen at:

Home Office Teletherapy

Client Consents?

Yes No

Should POA or Family be called First?

Yes No

Name

Relationship

Phone

Are you seeing or have you seen a therapist?

Yes No

Referral Reason

Insurance Information

Please attach a copy of your insurance cards(front and back) that will be billed for services

Front of Insurance Card

Back of Insurance Card

Social Security Number

Primary

Insurance Phone #

Policy #

Group #

Secondary

Insurance Phone #

Policy #

Group #

Does client accept responsibility as assigned by their insurance for copay/deductible/coinsurance?
Yes No

Billing Address (if different from Client Address above)

Name

Street Address

City

State

Zip