Referral - OriginSC

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

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

Name of Client:(Required)

Client Phone Number(Required)

Client Date of Birth

Name of other party involved(Required)

Relationship to client(Required)

Please check next to appropriate service/assessment requested for this client

Victim/Survivor of Domestic Violence Group

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. Session fees based on sliding scale: $40-$85 per 50-minute session. Insurance is not accepted.

Please specify if counseling for this client is:

DSS-recommended

Court-ordered or other organization

If court-ordered what Judge? If other organization please specify

Are there police/incident reports associated with the referral?

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

Max. file size: 25 MB.

You must agree to the following statement in order to submit this form

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.

Case Manager/ Referring Agent Information:

First and Last name(Required)

Agency and Title:(Required)

Email:(Required)

Phone number(Required)

Fax Number

Will the referring agency be paying the $65 assessment fee (does not apply to Victims Services)?(Required)

Yes

Will the referring agency be paying for counseling sessions and/or classes (does not apply to Victims Services)?(Required)

Yes

Other Information/comments

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.

BEHAVIORAL HEALTH SERVICES REFERRAL FORM