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Merion Village

Franklin County Counseling

What you need to have before seeing a provider:

  • Patient name, DOB, SSN, address, phone, email, insurance
  • Parent/Guardian name, DOB, SSN (insurance verification), address, phone, email

Proof of legal guardianship is required if not the biological parent or a custody situation

  • Requested services (psychiatry, case management, CANS assessment, individual therapy, family therapy)
  • Presenting concerns, symptoms, diagnoses, medications, history of/thoughts of self-harm, suicide attempts, violence, PCP, BH providers, specialists, and recent hospitalizations
  • Referral name, phone, email, and any other organizations involved (ROI required for all referring agencies). Court referrals require psychological evaluations completed for the court.

When a child is in the custody of Children's Services and living in temporary housing, the caregiver must bring specific legal and medical documentation to ensure the child can receive treatment:

Placement Paperwork: Official documentation from the agency (e.g., a placement agreement) confirming the child's residence.

Medical Consent Form: A signed authorization from the county agency or legal guardian allowing consent to medical treatment.

Proof of Custody: Any court orders or government-issued papers showing the child’s status as a dependent.

Guardian Identification: Photo ID and any "parent badge" or caseworker contact information provided by the agency.

Insurance or Medicaid Card: The child’s current medical card; for many children in care, this will be a state Medicaid card.

What to expect from your first appointment

  • An in-person appointment is required for first visits
  • A parent/legal guardian must accompany a minor 
  • Please bring up to date list of all current medications, medical conditions and any previously diagnosed mental health diagnoses
  • If possible, be aware of birth history and development  
  • Be aware of your preferred pharmacy and their address for medication prescriptions 

What to expect at follow-up appointments

  • May be in-person or telehealth depending on appropriateness 
  • A parent/legal guardian must always accompany the child for in person appointments or be available for telehealth appointments 
  • Follow ups can take 20 minutes to one (1) hour depending on appropriateness 

Contact Us!

For questions and all other inquiries, email us at counseling@southeastinc.com.

Franklin County Referral Form

MM slash DD slash YYYY

Referral Information

Your Email Address(Required)
Do you have a signed ROI for this referral(Required)

Patient Information

Patient Name(Required)
MM slash DD slash YYYY
Your Address(Required)
Your Email Address(Required)
Race

Ethnicity

Religious Preference

Preferred Language(Required)

Billing Information

Parent/Guardian Information (If under 18)

Parent/Guardian Name(Required)
MM slash DD slash YYYY
Preferred Language(Required)

Your Address(Required)
Your Email Address(Required)

Service Needs

Requested Services
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