Heights | Counseling Referral Request

Information provided will be used to match your needs to one of Heights' lay counselors or a counseling partner.

rev5.1.25

Your name *

Email address *

Request Information

What is the main reason you are requesting counseling? *

Do you feel like you are in CRISIS? *

Are you currently receiving psychiatric services, professional counseling or psychotherapy elsewhere? *

Counselor Preference? *

Additional Information About You

Phone number *

Address *

Gender *

Birthdate *

Marital status *

Employer:

Work Phone Number:

Family Members

Do you have a spouse or child/children that will be participating in counseling? *

HIPAA

Health Insurance Portability & Accountability Act (HIPAA)

HIPAA Privacy Rule *

In recognition of the integral role that family and friends play in a patient’s health care, the HIPAA Privacy Rule allows communication between health care providers and these persons. As stated in the regulations: "Where a patient is present and has the capacity to make health care decisions, health care providers may communicate with a patient’s family members, friends, or other persons the patient has involved in his or her health care or payment for care, so long as the patient does not object." (See 45 CFR 164.510(b)).

By my typed signature below, I grant permission for my lay counselor to share relevant information about my care with the pastors and Care Staff of Heights Church if they believe that it would be helpful to me and my healing process.

Type your full legal name below:

Date of Digital Signature: *