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*
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*

She/HerHe/HimThey/TheyAlternate Pronouns
Client's Cell Phone Number*
Client's Home Phone Number
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 PositiveAt RiskHIV 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

MedicareMedicaid (Highmark Health Options)Medicaid (Amerihealth Cartas)Ryan WhiteAetnaCignaHighmark DE (Commercial, BCBS or similar)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*

N/A (or not assessed)Low RiskMedium RiskHigh RiskAcute/Crisis
Depression*

N/A (or not assessed)Low RiskMedium RiskHigh RiskAcute/Crisis
Trauma*

N/A (or not assessed)Low RiskMedium RiskHigh RiskAcute/Crisis
Family Violence*

N/A (or not assessed)Low RiskMedium RiskHigh RiskAcute/Crisis
HIV Stigma*

N/A (or not assessed)Low RiskMedium RiskHigh RiskAcute/Crisis
Drug/Alcohol Abuse*

N/A (or not assessed)Low RiskMedium RiskHigh RiskAcute/Crisis
Cognitive Functioning*

N/A (or not assessed)Low RiskMedium RiskHigh RiskAcute/Crisis
LGBTQ Stigma*

N/A (or not assessed)Low RiskMedium RiskHigh RiskAcute/Crisis
Physical Health*

N/A (or not assessed)Low RiskMedium RiskHigh RiskAcute/Crisis
High Risk Behaviors*

N/A (or not assessed)Low RiskMedium RiskHigh RiskAcute/Crisis
Harm to Self*

N/A (or not assessed)Low RiskMedium RiskHigh RiskAcute/Crisis
Harm to Others*

N/A (or not assessed)Low RiskMedium RiskHigh RiskAcute/Crisis
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