AIDS Delaware Mental Health Referral Form

Thank you for completing this referral to the AIDS Delaware Mental Health Team. We will reach out to you and the client within one week to coordinate care.
Provider Information
Referring Provider First Name
Referring Provider Last Name
Referring Provider's Role/Position
Referring Provider's Employer/Source of Connection to Client
Referring Provider Contact Phone
Format: (000) 000-0000.
Referring Provider Email Address
example@example.com
Client Information
Client's (Legal) First Name
Client Goes By (if different than legal name)
Client's Legal Last Name
Client's Pronouns

Alternate Pronouns
Client's Cell Phone Number
Format: (000) 000-0000.
Client's Home Phone Number
Format: (000) 000-0000.
Client's Contact Preferences
Please note if client prefers phone, text, email, or any other helpful information so we can contact them.
Client's Email Address
example@example.com
HIV Status

HIV risk factors or relationship to HIV
Client's Date of Birth

MonthDayYear
Client's Social Security #
Please use numbers only (no dashes or other punctuation)
Insurance Information

Not required for services; please complete what you know.
Client's Primary Insurance

Other
Insurance Policy Number(s) (if known)
Risk Assessment and Treatment Needs

Please use your best judgment to rate the client's risk in the following areas.
Anxiety
Depression
Trauma
Family Violence
HIV Stigma
Drug/Alcohol Abuse
Cognitive Functioning
LGBTQ Stigma
Physical Health
High Risk Behaviors
Harm to Self
Harm to Others
Please provide any additional information that might be helpful to our clinical team.
Should be Empty:

Provider Information

Client Information

Insurance Information

Risk Assessment and Treatment Needs