Referral | YPYJ Healing Health

Home
Services
About Us
Billing
Contact
Current Clients

Client Referral Form

Please fill out our new client referral form and we will contact you.

Is the client agreeable and aware of this referral?YesNo

Is this referral urgent?YesNo

Client Information

First Name

Last Name

Date of Birth

Age

GenderMaleFemaleTransgenderNon-binary/non-confirmingPrefer not to respond

Parent/Guardian (in under 18)

FirstParent/Guardian (if under 18 years)

Last Name

Relationship with client

Contact Information

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Home Phone

May we leave a message?YesNo

Cell Phone

May we leave a message?YesNo

Email Address

May we email?YesNo

Insurance InformationIf you plan to use insurance, please enter your insurance information (We accept Blue Cross Blue Shield and MedCost)

Carrier

Policy Number

Please upload a front and back copy of your insurance card

Drag and Drop (or) Choose Files

Referral Source

First Name

Last Name

Phone

Services Requested

Services RequestedIndividual TherapyFamily TherapyCouples TherapyPsychological EvaluationsPsychoeducational EvaluationsKindergarten Readiness/Early Entry TestingCoaching Services

Presenting Problem(s) and Referral Question(s):

YPYJ HEALING HEALTH

Honor Your Path, Trust Your Journey.

Begin Your Journey

OUR PRACTICE

Our Mission

APPOINTMENTS & SERVICES

New Clients

Current Clients

Policies

Resources

Crisis Line

1415 W NC Highway 54
Building 300 Suite 121
Durham, NC 27701

Phone: (984) 439-8328
Email: [email protected]

Home
Services
About Us
Billing
Contact
Current Clients