MYC Counseling--Therapeutic Group Referral

This form is utilized for submitting a referral for therapeutic groups offered by Map Your Care Counseling.

Our groups are developed with evidence-based curriculum and help participants to build coping skills, navigate illness, caregiving and grief/loss, and find community.

By completing this form, you acknowledge the referred person has given consent to be referred and contacted by Map Your Care Counseling for the purpose of screening and providing additional information about group therapy options. Clients MUST be located in the state of Colorado to be eligible to participate.

Client Information

Name (First and Last)

Date of Birth

Phone Number

Email address

Emergency Contact/Caregiver (if applicable)

Emergency Contact/Caregiver Phone Number

Referring Provider Information (Skip section if self referral)

Name (First and Last)

Title

Name of Agency, Therapy Practice, Clinic, Physician Office, etc

Phone Number

Email address

Group Interest

Serious Illness Group -- starting January 2025 Caregiver Group -- starting January 2025 Anticipatory Grief Group -- starting Spring 2025

The Serious Illness Group is a best fit for those with an illness expected to progress over time, is life-limiting/is incurable, and has had a significant impact on a person's quality of life. This group is not a best fit for someone experiencing chronic pain/chronic illness not tied to a diagnosis similar to those listed below.

The Caregiver Group is a best fit for those caring for someone (generally, though not exclusively, as a primary caregiving providing physical and/or functional care) with a diagnosis similar to those listed below.

The Anticipatory Grief Group is a best fit for those caring for (either as a primary caregiver or a loved one not assisting with physical/functional caregiving) someone with an advanced or terminal illness, likely on/eligible for palliative or hospice care with approximately 1 year prognosis or less. This is not an exact science-Please continue the form regardless if the applicant would benefit from this support!

Other:

Accessibility Concerns Please note all groups are virtual via Zoom at this time

Hard of Hearing

Visual Impairment

Needs support in navigating Zoom technology

Other Accessibility Need (Describe)

Insurance Information Please note: This group is not eligible for clients receiving Medicaid at this time.

Traditional Medicare (NOT Medicare Advantage)

Kaiser Commercial

Kaiser Medicare

Cigna Commercial

Cigna Medicare

Private Pay

Please consider for reduced rate due to financial hardship

Unknown

Is there additional information about the client's needs that would be helpful for us to know?

To learn more about groups offered by Map Your Care Counseling, as well as other services, please visit our website at www.mapyourcarecounseling.com/groups

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MYC Counseling--Therapeutic Group Referral

Client Information

Referring Provider Information (Skip section if self referral)

Map Your Care: Illness & Grief Counseling