Referral Form

Benay’s Creative Counseling, LLC.
11923 Centre Street, Suite A9
Chester, VA 23831
804-592-0555 (Office)
804-655-6802 (Fax)

Referral Form
Client Name:*

First NameLast Name
Date:*

MonthDayYear
Date
Insurance Company:*
Policy Number (Include Prefix, if applicable) *
Date of Birth:*

MonthDayYear
Date
SS #:*
Gender:*
Marital Status:*
Race/Ethnicity:*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email Address:*
example@example.com
Parent/Guardian Name:*
Parent/Guardian Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Phone *
Please enter a valid phone number.
Referring Person & Agency:*
Referring Agency Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Referring Agency Phone:*
Please enter a valid phone number.
Purpose of Referral/Presenting Problems:

Check all that apply. Please include explain checked boxes below.
List*

History of TraumaHomelessHospitalizationChronic Medical ProblemsChronic Mental IllnessSexually InappropriateAuditory/Visual HallucinationsDelusions/Paranoid/ThoughtDisordersSadness/Depression/AnxietyDanger to Self/OthersVictim of Physical/Emotional AbusePeer Relationship ProblemsHistory of Substance AbuseSuicide Attempts (include dates and frequency)Deficits with ADLsAnger IssuesLegal InvolvementPhysical AggressionEating/Sleeping Disturbance
Provide your explanations for the above checkboxes below.*
Additional Information:
Method of screening:*

Face to FacePhoneVirtual-health
Signature of Person Completing Form:*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Purpose of Referral/Presenting Problems: