Client Transfer Form | Improving Lives Counseling Services

Now Hiring State-Wide Make A Referral Areas We Serve Frequent Questions Make A Payment

Clinician Name*
First Last
Client First Name*
Client First 5 of Last Name*
Client ThinkHealth ID #*
Date the client's TX Plan Expires*
MM slash DD slash YYYY
Client's Primary Insurance*
Client's Secondary Insurance*
Client Phone Number*
Client Email*
Approximate Age*
Reason for Transfer*
Clinician Transferred To (If Known)
Requestor's Email Address ( To be emailed a copy of the submission )*

Man in behavioral therapy