Camelot Referral Form

MAKE A REFERRAL

Know someone who would benefit from our services? Complete our Camelot Referral Form and an Authorization to Release Information Form, and our Camelot Psyckes Consent Form then use the option below to upload these forms. If you prefer, you can also email it to us at admin@camelotcounseling.com or fax it to 718-981-9344.

Downloadable Forms: Camelot Consent Form and Psyckes Consent Form

ONLINE REFERRAL FORM

Complete our quick online referral form and a staff member will be in touch to provide/request further information.

Consumer's Name*
First Last
Consumer's Primary Insurance Provider*
Consumer's Primary Insurance ID Number*
Consumer's County and State Of Residence*
Consumer's Age*
Consumer's Gender*
Consumer's Marital Status*
Referring Provider*
Name of Person Making The Referral*
First Last
Referral Source's Primary Email Address*
Referral Sources Primary Fax #
How Would You Like To Be Contacted?*
- Select All
- Email
- Phone
- Fax
Reason For Referral*
Services being Requested*
Press The Shift Button To Make Multiple Selections
Form Uploads
Please complete our forms above and upload them along with a physical exam and mental status form. If you prefer, you can also email these forms to admin@camelotcounseling.com or fax them to 718-981-9344
Max. file size: 128 MB.

Contact Us:

Camelot of Staten Island, Inc.

Address: 4442 Arthur Kill Road, Suite 4

Staten Island, NY 10309

Phone: 718.356.5100