Envision Healthcare Services, LLC
145 Highway 15-401 Bypass West Ste. 9
Bennettsville, Sc 29512
Office: 843-456-5045
Crisis: 843-267-5207
Fax: 843-258-5065
Please Submit this form, along with copy of valid Insurance card, to EHS via Fax 1 (843) 892-2581 or Email
referral@envisionhs.com. To make an appointment call (843) 456-5045.
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Month
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Year
Date
Requested Services:
Behavioral Health Screening
Diagnostic Assessment
Service Plan Development
Crisis Management
Individual Therapy
Group Therapy
Family Therapy
Foster Care
BENFICIARY INFORMATION
Beneficiary Full Name:
First Name
Last Name
Preferred Name/Nickname:
Social Security #:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Mobile Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Email
example@example.com
Email:
Marital Status:
Primary Language:
Is Individual Proficient in English?
Yes
No
Date of Birth
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1924
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1922
1921
1920
Year
Gender
Please Select
Male
Female
Not willing to Disclose
Phone Number
Insurance?
Yes
No
Highest Grade Completed:
Type of Insurance:
MCO:
County/State:
Policy #:
Guardian/Legally Responsible Person Information
Yes
No
Name:
Relationship to Beneficiary:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Mobile Phone:
Work Phone:
Emergency Contact Information
Yes
No
Name:
Relationship to Beneficiary:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referral Source
Yes
Self
Agency:
Contact Name/Title:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone:
Fax:
Email:
Reason for Referral:
Back
Next
Current Symptoms:
Depressive Symptoms
Unexplained fear/isolation
Anxious/Excessive Worry
Disruptive/Oppositional Behaviors
Easily upset/agitated/angered
Hyperactivity/impulsiveness
Inability to focus/Distracted easily
Bizarre thoughts/actions
Hallucinations (Visual, Auditory, Olfactory)
Paranoia/people out to get you
Self-Harm/Mutilation
Poor concentration
Trauma/Acute Stress
Grandiose thinking
Suicidal Ideation
Hearing voices
Flight of Ideas
Racing thoughts
Diagnosis
Description
Diagnosis Date
Diagnosed By
Diagnosis Code
Diagnosis Code
Diagnosis Code
Back
Next
Current Medications:
Yes
No
Is Medication Management Needed?
Yes
No
Dosage
Frequency
Purpose
Medication
Medication
Medication
Prescribing Physician
Is the Beneficiary involved with any other agencies? If yes, When & Which agency?
Has there been any DSS involvement? If yes, When & Explain?
Has there been any law enforcement involvement? If yes, When & Explain?
Have there been any hospitalizations? If yes, When & Explain?
Is the individual a danger to self or others? If yes, Explain?
Indicate how EHS will be rehabilitative for the beneficiary?
SIGNATURES
Person Making Referral: (Print Name)
Date
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Month
-
Day
Year
Date
Title:
Person Making Referral: (Signature)
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