Primary Care Physician Notification

It is often helpful to notify your doctor of mental health or substance abuse treatment so that your doctor can let us know of any possible medical issues that may affect treatment. In some cases medications or medical issues can cause or worsen mental health or substance use issues. Most insurance companies also request that therapists and psychiatrists notify primary care physicians about mental health or substance abuse treatment.
Please check the appropriate box below. Checking the “Yes” box and signing this form will allow Congruent Counseling Services, LLC to notify your primary care physician. If you do not wish for us to notify your PCP, then please select “No” and sign. This is required by your insurance company.
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- No, I would not like Congruent Counseling Services to notify my PCP.
- Yes, I would like Congruent Counseling Services to notify my PCP.
Physician Name*
First Last
Physician Address
Street Address City State / Province / Region ZIP / Postal Code Country
Physician Email*
Physician Phone*
Disclaimer*
- I agree to receive communications by text/SMS about my inquiry. Terms & Conditions: By clicking the box you agree to subscribe to Congruent Counseling Services (CCS) text/SMS services and to receive text messages from CCS. CCS will send text/SMS messages to communicate with you on the status of sessions or information requested to provide a better overall experience. For HELP, please contact us at +1 410 740 8066, or email frontdesk@ccs-ic.com. To opt-out of receiving messages, reply with “STOP” at any time. Message frequency may vary. Standard message and data rates may apply. You may review our Privacy Policy to learn more about how your data is used. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.
Physician Fax
Email*
Client Name
Name of Clinician
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