Referrals

Please complete the PERSONAL REFERRAL FORM FOR INDIVIDUALS if you are seeking counseling services for yourself or someone under your care.

Please complete the PERSONAL REFERRAL FORM FOR COUPLES if you are seeking couples counseling services.

If you are a healthcare provider or referring on their behalf, please complete the PROFESSIONAL REFERRAL FORM or FAX a referral to 336-283-3827. 

We are dedicated to protecting our clients' privacy. Information submitted on this form is confidential, encrypted, and secure.

Currently, potential new clients can expect a 2-3 month wait before services begin, possibly longer if afternoon hours are required. 

Clients and referring providers will be contacted by one of our care coordinators if additional information is required, and again when an appointment becomes available. If you have questions, please e-mail our Client Care Team at: OfficeAdmin@kernersvillecounseling.com