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

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Who should be contacted to schedule the appointment? *
 

Current Issues/Symptoms/ Problems

Reason for Referral: * 
 
Do you have allergic/adverse reactions to anything? *

Appointment Information

Which services are you in need of? *
Appointment Preference *
Therapist 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. *

Person Making the Referral

Preferred Method of communication with us: *
 
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