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Brighter Pathways, LLC
Referral Form
Thank you for choosing Brighter Pathways, LLC. To make a referral for services at our practice, please fill in the information below.
Patient Information
Today's Date
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Birth Date (MM/DD/YYYY)
*
Daytime Phone
*
First Name
*
Middle Initial
Last Name
*
Current Diagnosis
Age
*
Who should be contacted to schedule the appointment?
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Person making referral
Person being referred
Parent/Guardian
Other
Other
Name
Telephone number
Relationship:
Email Address
Current Issues/Symptoms/ Problems
Reason for Referral:
*
🛈
Assessment only
Individual Therapy
CBT Group
Family Therapy
Money Coaching
Nutrition/Wellness Coaching
Other
Other
Do you have allergic/adverse reactions to anything?
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Yes
No
Appointment Information
Which services are you in need of?
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Assessment Only
Individual Therapy
Family Therapy
Group Therapy
Employee Assistance Program(EAP)
Other
Appointment Preference
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Morning (9a- 12p)
Afternoon(After 12p-4p)
Evening (4:30p- 7:00p)
Saturday/Sunday
No Preference
Therapist Preference:
*
Male
Female
No Preference
Insurance Information
Do you have medical Insurance? *Please check with office to ensure we are provider's in your network or if you have out-of-network benefits :Please also note payment, if required, is expected at the time services are rendered. * Some groups are not covered under insurance.
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Yes
No
Primary Insurance
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Relation to the insured
*
Self
Spouse
Child
Other
Secondary Insurance
Relation to the insured
Self
Spouse
Child
Other
Person Making the Referral
First Name
*
Last Name
*
Phone #
*
Fax
*
Email Address
*
Preferred Method of communication with us:
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Phone
Fax
Email
Other
Other
Thank you for the referral. Someone will be in contact with you or the person you referred within 1 business day. If you have not heard from our office within 24 hours, please feel free to follow up with a call or email.
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100 Ashland Park Lane, Suite E Columbia, SC 29210
Phone: 803-708-7990 Fax: 803-636-2637
Website: www.brighterpathways-sc.com
Email:brighterpathwaysllc@gmail.com