Make a referral Complete the referral form below to request services, share details, and help our team understand your needs better. Good deeds behavioral health services,LLC Changing lives, one good deed at a time. 843-225-5742 843-225-5742 info@gooddeedsbhs.com Referral source Date Agency/Person Phone Number Fax Number Email Address Client info Name Date of Birth SOC. SEC Address Gender Male Female Client's Phone Number Other Insurance Type Policy# Primary Care physician Name Primary Care physician's Phone Number Does client have any other form of insurance? Yes No If Applicable Biological Parent Legal Guardian Parent / Guardian / Other Parent Home Phone Other Emergency Contact Emergency Home Phone Other Reason(s) for referral Check All That Apply Clinical Assessment Individual Therapy Family Therapy Group Therapy Parent Support / Consultation Psychoeducational Evaluation Other Brief Description of Problem Submit Referral