NBFS Referral Form

NBFS Referral Form
DATE OF REFERRAL

MonthDayYear
Date
PROGRAM

Intensive In-Home ServicesMHSSOther
CLIENT DEMOGRAPHIC, INSURANCE, AND DIAGNOSTIC INFORMATION
Name
Date of Birth

MonthDayYear
Date
Address
Phone Number
Please enter a valid phone number.
Gender
Race
Social Security Number
Medicaid Number
Medicaid Insurance Type

AnthemVA PremierMCC of VASentaraAetnaUHC/Optum
PARENT/LEGAL GUARDIAN/AUTHORIZED REPRESENTATIVE (If applicable)
Name
Relationship
Address
Cell Phone
Work Phone
Chief Complaint/Presenting Problem
PLEASE CHECK ALL PROBLEM AREAS THAT APPLY TO THIS CLIENT:
Type a question

DepressionAnger/AggressionAnxietyExpressing Feeling/EmotionsViolence/Property DestructionFamily/Relationship IssuesStabilize Psychiatric SymptomsNoncompliance/DefianceSuicidalityDifficulty Sleeping/EatingSelf-harmSubstance/ Alcohol Use/AbuseGang InvolvementLegal InvolvementOther:
DMAS and DBHDS CRITERIA FOR IIH (Must meet 2 of the 3 criteria below)
The individual is experiencing repeated behavioral/mental health concerns in the home, school, and community that are placing him/her at

risk of out of home placement or to a higher level of care?

The Individual's behaviors/concerns have required repeated Interventions (outpatlent, med mgt., probation, IEP, CPS/Foster Care, etc

The Individual has impaired cognition such that he/she places others and themselves at risk of harm or Injury (lacks remorse, deliberate

acting out, repeated behaviors despite consequences, not learning from mistakes, etc

OTHER REQUIREMENTS FOR PARTICIPATION:

At least one (1) parent/guardian is willing to participate in services

The individual (client) is willing to participate in services

The individual and parent/guardian agree to a referral for outpatient services as required by regulations (only if not alreody receiving)
REFERRING PARTY NAME
REFERRING AGENCY
MAILING ADDRESS
Phone Number
Please enter a valid phone number.
E MAIL ADDRESS
example@example.com
Should be Empty:

NBFS Referral Form

CLIENT DEMOGRAPHIC, INSURANCE, AND DIAGNOSTIC INFORMATION

PARENT/LEGAL GUARDIAN/AUTHORIZED REPRESENTATIVE (If applicable)

PLEASE CHECK ALL PROBLEM AREAS THAT APPLY TO THIS CLIENT:

DMAS and DBHDS CRITERIA FOR IIH (Must meet 2 of the 3 criteria below)