Metis Counseling Group Referral Form

Metis Counseling Group Referral Form

1515 W. Cornwallis Dr, Suite 207, Greensboro, NC 27408 · Tel: (336) 937-3146 · Fax: (336) 585-6269
General Patient Information
Client's Full Name

First NameLast Name
Date of Birth

MonthDayYear
Client Phone Number
Format: (000) 000-0000.
Client Email
Diagnosis (if known)
Insurance Provider (if any)
Referral Information
Referral Source
Name and organization/practice of the person making this referral
Referral Source Phone Number
Format: (000) 000-0000.
Referral Source Email
Date of Referral

MonthDayYear
Is the patient aware of this referral?
If yes, is the patient requesting treatment?
Is the patient currently in mental health treatment?
Name of current provider
Has the patient had previous mental health treatment?
Name of previous provider
Upload Client Insurance Information and/or Release of Information (ROI) Form

Upload a File
Optional. You can upload more than one file (PDF, image, or Word document). Cancelof
Other – Please Specify
Please provide additional details regarding any clinical concerns, symptoms, or treatment needs not addressed in the selections above (100 characters maximum).
Clinical Features

Check all that apply
Clinical Features
If Other, please describe
Should be Empty:

General Patient Information