Client Referral Form

Private pay practice located in South Park area of Charlotte

Cheryl D. Perry MA LPCA NCC

Date of Referral

Referring Provider Name

Practice/Clinic Name

Phone

Patient information

First name

Last name

Address

Cell/Home Phone

Work Phone

Date of Birth

Legal Sex

Perry Wellness Counseling recognizes a number of genders and sexes and is LGBTQ affirming

Relationship Status

Single Married Committed Relationship Divorced Widowed

Clinical Information

Reason for Referral

Diagnosis

Primary mental health diagnosis

Secondary mental health diagnosis

Relevant medical diagnoses

Relevant social factors

Mental Health History

History of violence toward others or survivor of domestic violence?

Yes No

Please provide details

History of suicide attempts?

Yes No

Please provide details

History of psychiatric hospitalizations?

Yes No

Dates

Previous symptoms and diagnoses

Current Mental Health Treatment and History

Current symptoms

Current suicidal/homicidal thoughts?

Yes No

Please provide details

Current psychiatric medications (name and dose)

Primary Care Physician

Phone Number

Your message will be encrypted and can only be read by Cheryl D. Perry MA LPCA NCC.

Cheryl D. Perry MA LPCA NCC

Owner/Clinician, Perry Wellness Counseling, PLLC

Cheryl is a Board Certified Licensed Professional Counselor Associated in private practice. Cheryl has a warm and inviting sense to counseling and sessions are focused on the client and meeting them exactly where they are at the moment. Cheryl works with adults struggling with symptoms of stress and anxiety, and she helps clients facing life transitions such as a new medical diagnosis, grief, loss, or becoming a caretaker to an ailing loved one. She works with clients to feel comfortable to speak openly about their feelings and feel empowered to make positive change.

(980) 270-1939
www.perrywellnesscounseling.com
perrywellnesscounseling
perrywellnesscounseling
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perry_wellness
6733 Fairview Road, Suite B, Charlotte, NC, 28210