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*
Physician Fax
Email*
Client Name
Name of Clinician
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