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Corporate Request Form
1.  DATE:

1. DATE:

Date
2.  Name and Position of Individual Making Request:

2. Name and Position of Individual Making Request:


3.  What services are you considering?

3. What services are you considering?

Describe what you have in mind.

4.  Describe your Needs

4. Describe your Needs

Testing Companies: What are the testing products of your Company?
Clinics and Hospitals: In what areas do you need a Genetic Counselor?  Cancer, Prenatal, Neurology, Cardiology?  

5.  If you need us to speak to patients, which response do you request?

5. If you need us to speak to patients, which response do you request?

Check as many options that seem acceptable
6.  Specialty of Genetic Counselor Requested

6. Specialty of Genetic Counselor Requested

Most Genetic Counselors have several areas of speciality, although we try to match assignments to the areas of primary focus and current clinical expertise of our Counselors.  

Unique or Complex Projects that need immediate launch are handled through training sessions in  joint collaboration between your team and Genetic Counseling Services.  

You may check as many options as you need.

7.  How do you market your tests or services?

7. How do you market your tests or services?


8.  How many clients/patients per week to speak to a Genetic Counselor?

8. How many clients/patients per week to speak to a Genetic Counselor?


9.  In which states are clients located?

9. In which states are clients located?


10.  Describe your anticipated growth within the 3,6,12 mos.

10. Describe your anticipated growth within the 3,6,12 mos.

In any states or countries, in particular. 

12.  When do you need to implement this service?

12. When do you need to implement this service?

Ex: ASAP, within 1 month, within the next 3 months, by end of year?

13.  YOUR CONTACT INFORMATION

13. YOUR CONTACT INFORMATION

Email, cell phone, etc.   Also, what is the best time to call you, as well as your time zone? 

14.  Verifier

14. Verifier

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Discussions with a genetic counselor as offered by Genetic Laboratories and Genetic Testing Companies serve to provide key information for the understanding of genetic testing, although pedigree intake and record review may be focused to the results of genetic testing.  Although laboratory license and permit and genetic counselor certification and licensure where applicable, do not permit the practice of medicine, genetic counselors can provide explanation and direction to physicians and authorized medical professionals for the interpretation of the results of genetic testing.  Genetic counselors, upon physician waiver and in collaboration with ordering clinicians, can provide counseling on genetic testing and the meaning of test results. Comprehensive genetic counseling may be available through physicians who can provide genetic counseling within the scope of their practices as they choose and through genetic counselors within the scope of their practice. Please note that patient management and genetic counseling surrounding on-going prenatal or any diagnostic testing is best handled by Physicians, Maternal/Fetal and Pediatric Genetics specialists,  in conjunction with clinical services where they are available and in collaboration with genetic counselors and other genetic specialists. 

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info@geneticcounselingservices.com