Enroll as a Business or Church Sponsor
This form is required for EACH individual you wish to sponsor.
Organization Name:
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Your Name (Must be an Authorized Representative)
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First Name
Last Name
Your Phone Number
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Please enter a valid phone number.
Patient's Name (the employee or organization member you are referring)
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First Name
Last Name
Patient's Phone Number
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Please enter a valid phone number.
Has the patient been informed of your intention to sponsor professional counseling services? If no, the organization must inform and acknowledge acceptance from patient prior to completing this form.
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Yes
No
Fee schedule
Fee is $90 per 1 hour session.
How many 1-hour sessions would you like to sponsor for the patient?
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Unlimited. Continue therapy as often and for as long as needed.
4 sessions
8 sessions
12 sessions
Payment method:
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Organization's Credit/Debit Card. Charged per session.
Organization's Credit/Debit Card. Charged in intervals of 4 session.
Organization's Credit/Debit Card. Prepaid for total number of sessions.
Cash / Check (due at the time of service, or prior to service)
Additional information:
Next steps:
Our Patient Coordinator will call you to verify information and collect payment over the phone. If you do not receive a call within 2 business days, please contact 843-894-0000. Please note, organizations do not have authorization or access to electronic health records of the patient, regardless of payor.
Type a question
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Please verify that you are human
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