Referral Process
If you would like to refer yourself or others to RHEMA Counseling & Support Services, we encourage you to carefully read through our Counselor-Client Agreement listed below. This will hopefully address any questions or concerns that you may have regarding the counseling process and our practice policies and procedures.
We also advise that you read our Notice of Privacy Practices and our policy regarding the treatment of Minors. You will have the opportunity to review and discuss each of these forms during your initial appointment.
Once you have read these documents, please complete the Client Referral Form (one form for each referral) and fax to our office at 919-544-1331. You are always welcome to call to discuss your referral, the referral process and submission or with any further inquiries at 919-544-1300.
In addition to the referral form, all active clients must sign statements giving us consent to treat you or your minor child and statements acknowledging that you have received, read and had the opportunity to discuss specific information detailed in the counseling-client agreement. This information is located on the Consent To Treat and Acknowledgment Form. Please make sure that all of your questions are addressed prior to signing this form.
Thank You For Your Referral
Screening & Referral Form
Consent to Treat (Non-Medicaid & Medicare Recipients)
Consent To Treat (Medicaid & Medicare Recipients Only)
Counselor - Client Agreement
Notice To Parents
HIPPA & Client Rights
We also advise that you read our Notice of Privacy Practices and our policy regarding the treatment of Minors. You will have the opportunity to review and discuss each of these forms during your initial appointment.
Once you have read these documents, please complete the Client Referral Form (one form for each referral) and fax to our office at 919-544-1331. You are always welcome to call to discuss your referral, the referral process and submission or with any further inquiries at 919-544-1300.
In addition to the referral form, all active clients must sign statements giving us consent to treat you or your minor child and statements acknowledging that you have received, read and had the opportunity to discuss specific information detailed in the counseling-client agreement. This information is located on the Consent To Treat and Acknowledgment Form. Please make sure that all of your questions are addressed prior to signing this form.
Thank You For Your Referral
Screening & Referral Form
Consent to Treat (Non-Medicaid & Medicare Recipients)
Consent To Treat (Medicaid & Medicare Recipients Only)
Counselor - Client Agreement
Notice To Parents
HIPPA & Client Rights