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Home
Programs
Homeownership
Homebuyers
Reverse Mortgage Counseling
Lending
Financial Education & Coaching
Financial Coaching
Student Debt Solutions
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
Family Violence Intervention
Anger Management
Batterers Intervention
Domestic Violence Victims Program
Workshops
FREE Intro to Homeownership Workshop
FREE Credit Improvement & Making Ends Meet Workshop
Ehome America Homebuyer Course
Bankruptcy Counseling
Reverse Mortgage
Men’s Batterers Intervention
Men’s Anger Management
Women’s Anger Management
Women’s Batterers Intervention
Virtual Classroom
Invite us to your location
Get Involved
Careers
Special Events
Volunteer
Donate Now
Give to Stability
Survivors of Crime Donations
About
Annual Reports
Our History
Our Impact
Our Staff
Our Board
Privacy Policy
Contact
843.628.3000
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Referral
Referral
BEHAVIORAL HEALTH SERVICES REFERRAL FORM
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
NO
Name of Client:
(Required)
Client Phone Number
(Required)
Client Date of Birth
Name of other party involved
Relationship to client
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?
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
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
No
Will the referring agency be paying for counseling sessions and/or classes (does not apply to Victims Services)?
(Required)
Yes
No
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.
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