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Home
Programs
Homeownership
Homebuyers
Lending
Reverse Mortgage Counseling
Financial Education & Coaching
Financial Coaching
Student Loan Counseling
Bankruptcy Counseling
Pre-file Bankruptcy
Post-file Bankruptcy
Debt Management
Professional Fiduciary Services
Conservator
Conservator Financial Education & Counseling
Trustee
Personal Representative / Executor
VA Fiduciary
Power of Attorney Agent
Representative Payee
Housing Stability
Eviction Prevention
Foreclosure Prevention
Mental Health Counseling
Individual & Couples Counseling
Group Counseling
Anger Management
Batterers Intervention
Survivors of Domestic Violence / Empowerment
Workshops
FREE Intro to Homeownership Workshop
FREE Credit Improvement & Making Ends Meet Workshop
Ehome America Homebuyer Course
Bankruptcy Counseling
Men’s Batterers Intervention
Men’s Anger Management
Women’s Anger Management
Women’s Batterers Intervention
Virtual Classroom
Get Involved
Careers
Special Events
Volunteer
Donate Now
Donate to Origin SC
Survivors of Crime Donations
About
Annual Reports
Our History
Our Impact
Our Staff
Our Board
Our Blog
Privacy Policy
Contact
843.628.3000
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Referral
Referral
BEHAVIORAL HEALTH SERVICES REFERRAL FORM (1)
This form is only to be used by case managers and referring organizations. If you are referring yourself you need to call 843-628-3000 option 0 and speak to someone during business hours. Business Hours are Monday-Thursday 8:00 AM-5:00 PM, Friday 8:00 AM- 4:00 PM
Referring Agency
(Required)
Choose One
DSS
Other
Your First, Last Name, and Title
(Required)
Your Organization (if applicable):
Your Phone number
(Required)
Your Email:
(Required)
Your Fax Number
DSS County
(Required)
Client Information
Would you like Origin SC to reach out to the client (by clicking yes, you affirm it is safe to contact them with the phone numbers you are providing)?
(Required)
Yes
NO
Name of Client:
(Required)
Client Phone Number
(Required)
Client Date of Birth
Name of other party involved
(Required)
Relationship to client
(Required)
Preferred Counselor (if any):
Reason for Referral
(Required)
Please check next to appropriate service/assessment requested for this client
Survivors of Domestic Violence Group/ Empowerment
16-week psychoeducational group counseling, court advocacy, and support for victims and survivors of domestic and intimate partner violence. FREE of charge.
Anger management
Anger Management is a 16-week psychoeducational group counseling and support for non-abusive individuals with anger issues. An initial assessment is required, the fee is $65 (fee will not be waived for any reason). Classes are $35 per weekly class. For classes only, sliding scale/financial assistance available on case-by-case basis. Insurance is not accepted.
Batters Intervention
The Batterers Intervention Program is a 26–32-week psycho-educational group counseling and support for offenders. An initial Assessment is required, assessment fee is $65 (fee will not be waived for any reason). Classes are $35 per weekly class. For classes only, sliding scale/financial assistance available on case-by-case basis. Insurance is not accepted.
Individual Counseling / Psychotherapy
Individual Counseling / Psychotherapy is a Client-centered treatment approach. Length and frequency of treatment will vary based upon the individual needs of the client. Individual Counseling sessions are $100/session. Sliding scale available on a case-by-case basis. Insurance is not accepted.
Are there police/incident reports associated with the referral?
(Required)
No
Yes-If yes, please include a copy of the report(s) with referral.
Please upload any copy's of police/incident reports here
Drop files here or
Select files
Max. file size: 25 MB.
You must agree to the following statement in order to submit this form
(Required)
I agree that I have provided Origin SC with all fact-based police and incident reports that are relevant to this referral. These reports aid in providing an accurate diagnosis and appropriate treatment plan for the individual.
Will the referring agency be paying the $65 assessment fee (does not apply to Victims Services)?
(Required)
Yes
No
Will the referring agency be accepting financially responsible for the cost of Anger management and/or Batters Intervention group counseling. The cost of anger management is $35 per class x16 Sessions=$560. Batters Intervention is $35 per class x 26 sessions= $910 total. (Origin SC does not allow outside organizations to be financially responsible for the cost of for Individual Counseling / Psychotherapy. This needs to be paid at the time of service and is not something we currently bill for)
(Required)
Yes
No
Other Information/comments
Please upload any of documents IE: court orders, incident reports, discharge summaries ETC.
Max. file size: 25 MB.
I Agree
(Required)
By checking this box you are confirming you have provided Family Services DBA OriginSC ALL police/incident reports associated with the referral (if you are unable to upload them please email them to referrals@originsc.org) . That you agree with all information that you put on this form including who is responsible for payment. You are also affirming that you are a case manager or other referring agency and that you are not filling this form as a self-referral.