Individual Status Notification Individual's Status NotificationBelow is a review of the current status of the individual you referred to Still Waters Professional Counseling Services, Inc.Submitted By: Still Waters Professional Counseling Services, Inc.3711 Executive Center Dr. • Augusta, GA 30907 • Office: 706-955-9224 • Fax: 706-955-9349 • www.stillcorp.comDate MM slash DD slash YYYY Submitted By Name: First Last Still Waters Employee’s name who is submitting this form.Submitted By Email Still Water’s Employee’s email – the email from the person who is submitting this form.Referred Individual's Information & StatusReferred Individual First Middle Last Suffix Current Status Discharging Referring Out Currently In Services Non-Compliant Inactive Insurance No Units Left Need Additional Units Unable to Reach Individual Urgent Notification Need Information Describe selected field(s) above.Submitted To InformationProvide the referral source information and for who this Individual’s Status Notification is intended.Submitted To Name First Last Provide name of person you are sending this notification to.Submitted To Company Provide the company name of person you are sending this notification to.Submitted To Email: Provide email of person you are sending this notification to. Mandatory for this email to send out.Submitted To PhoneProvide phone number of person you are sending this notification to. (optional)Submitted To FaxProvide fax number of person you are sending this notification to. (optional) Δ
