I.C.A.R.E. Online Self Referral Form — I.C.A.R.E Counseling Services, PLLC

Please complete this form in its entirety so that we have all the information needed to place you with the right clinician and are able to verify your insurance.

ALL REFERRAL PARTNERS, PLEASE FAX ANY

MEDICAL-RELATED DOCUMENTS TO 336-376-6425.

How did you hear about ICARE Counseling? *

Patient Name *

First Name

Last Name

Parent or Legal Guardian Name

First Name

Last Name

Phone Number *

Please use the parent or guardian's phone number if the patient is under 18yo.

Patient Email *

Please use the parent or guardian's email address if the patient is under 18yo.

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

YYYY

Sex *

Gender

Race & Ethnicity *

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latinx

Middle Eastern or North American

Native Hawaiian or Other Pacific Islander

White

Race or ethnicity not listed

INSURANCE INFORMATION

Does the person seeking service have insurance? *

Insurance Provider (List All Policies) *

For Medicaid Recipients, please list the plan name. Ex: VAYA HEALTH If you do not have insurance, please place N/A here.

Insurance Member ID Number *

For Medicaid Recipients, please enter your member id number. If you do not have insurance, please place N/A here.

Medicaid Recipient Number

For Medicaid Recipients, please use the number starting with 9 and ending in a letter.

REQUESTED SERVICES

Requested Service (Please check all that apply) *

Comprehensive Clinical Assessment

Trauma Informed Comprehensive Clinical Assessment: CHILD

Outpatient Therapy: INDIVIDUAL

Outpatient Therapy: COUPLES/FAMILY

Outpatient Therapy: GROUP

For Trauma Informed Comprehensive Clinical Assessments: CHILD

Please include: Identified Trauma(s), Supportive Caregiver Name, Supportive Caregiver Relationship to Patient, and Supportive Caregiver #.

REASON FOR REFERRAL

Reason for referral *

What are your symptom/behaviors, where do they occur, how often do they occur, when did symptoms begin?

ADDITIONAL INFORMATION

Psychiatric Diagnosis (if known)

Current and/or Prior Treatment (if known)

Medical Conditions & Allergies

Primary Care Physician & Phone #

Medications (include dosage)

Thank you for your submission! Someone from our team will contact you within 24-48 hours

If you are experiencing a mental health emergency, please dial 988. If you are experiencing a medical emergency, please dial 911 now.

Please remember to fax over any medical-related documents to 336-376-6425.

Thank you,

ICARE Counseling Team

Stay in touch.

106 S. Fourth St. Suite A

Mebane, NC 27302

Email: admin@icare-counseling.com

Tel: (919) 649-3952

Fax: (336) 376-6425

Questions?

2024 I.C.A.R.E Counseling Services, PLLC.