Referral Form Leave this field blank Referral Form CLIENT DEMOGRAPHIC INFORMATION: Date of Birth: Grade: Marital Status: Married Single Divorced Separated Widowed REASON FOR REFERRAL: Service: Individual Family/Couple Group SUD/DWI/DOT School Referral Sex Offender Services Other Preferred Location: Winston-Salem Thomasville Reidsville Telehealth King Additional Information: CONFIDENTIALTY: Consulting is a confidential process designed to help you address yourconcerns and come to a greater understanding of yourself by learning effective personal andinterpersonal coping strategies. All interactions with HOPE Counseling & Consulting Services,including scheduling of or attendance at appointments, content of your sessions, progress incounseling and your records are confidential. HEALTH INSURANCE INFORMATION: Referral Source: Date: Referral Signature: I agree that my name below will be as valid as a handwritten signature to the extent allowed by local law Drawing Signature Clear Done Start Over Submit
