Agency & Physician Referrals

Making a Referral:

Matone Counseling and Testing is proud to work with local healthcare providers to provide services for identified clients. We understand the importance of whole person, integrated care and look forward to partnering with you.

Referrals can be made by submitting our referral form directly here via the website, or by downloading the pdf version below and sending via fax.

Referral Agency Contact Information (person making referral):

First

Last

Name of Referral Agency

Referral Agency Phone Number

Referral Agency Fax Number

Referral Agency Contact Email Address

Please describe the purpose of the referral:

Type of Treatment (check all that apply):

Counseling
Psychological Evaluation

Client Name

First

Last

Client Date of Birth

Parent/Guardian Name (if applicable)

First

Last

Best Phone Number for Client Contact

Best Email Address for Client Contact

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Language

Insurance Provider Type and ID Number

Name of Primary Insured (if not client)

Matone Counseling and Testing is proud to work with local healthcare providers to provide services for identified clients.

Fax Referral Form

Print and fill out the PDF and Fax to 980-498-6700.

PDF Referral Form

Following Up on a Referral:

Due to our high call volume, Provider Updates are sent out via fax or email (upon request) ONLY.

Please fax requests for updates to 980-498-6700, or email support@matonecounseling.com. Provide your fax number in your request so we can fax a response.