Coordination of Care

(Individual's) Member Name

First Last Suffix

(Individual's) Member ID Number

(Individual's) Date of Birth

(Individual's) Member Consent Status

Member has signed an authorization form allowing me to exchange pertinent information “must be marked if information provided”

Still Waters Professional Counseling Services, Inc. • 3711 Executive Center Dr. Martinez, GA 30907 • Phone: 706-955-9224 • Fax: 706-955-9349

Primary Care Provider and/or Specialist Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Fax

Still Waters is treating the individual for the following diagnosis(es):

The individual is taking the following medications that we prescribed:

The individual is engaged in the following psychotherapeutic intervention(s):

Frequency of interventions:

Coordination of care issues / other significant information affecting medical or behavioral health care:

Name

First Last Suffix

Title

Signature of person completing this form:

Date mailed or faxed: