* Required Information

Client Information

Insurance Information

Belief Counseling, LLC accepts: Florida Blue, Oscar Health, United Health, Cigna, Aetna, and Self-Pay.

Reason for Referral

Attachments


Consent for Referral

I confirm that I have discussed this referral with the client and/or their legal guardian, and they consent to being referred to Belief Counseling, LLC for mental health counseling services.

I confirm that I am the client, the client's legal guardian, or an authorized individual or referring professional, and that the client and/or legal guardian is aware of and agrees to this referral to Belief Counseling, LLC for mental health counseling services.

I understand that any personal and, when applicable, health-related information submitted through this form will be used to review and coordinate services and will be handled in accordance with applicable privacy laws and the practice's Privacy Policy and related policies.

Select a country first.