REFERRAL & SCREENING FORM

Date of Referral

Date

Referral Type

How did you hear about Virginia Family Services?

REFERRING PARTY

Name

First NameLast NameSuffix

Referring Agency

Position/Title

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

INDIVIDUAL INFORMATION

Name

First NameLast Name

Date of Birth

Date

Age

SSN

Ethnicity

Assigned Gender

Gender Identity

Do you have an alternative gender preference?

Do you currently have stable housing?

Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If no, where can we locate you?

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Best time to Call

Parent/Legal Guardian Name (If Applicable)

Parent/Legal Guardian Phone:

Please enter a valid phone number.Format: (000) 000-0000.

PRESENTING CONCERNS

Please Select Presenting Concerns

SERVICES OF INTEREST

Service(s) of Interest

Have you been discharged from any 30-day Substance Use Inpatient Programs or Inpatient Hospitalization in the past 60 days?

Recommended Service

Have you ever been previously diagnosed with any of the following disorders?

Are you currently prescribed any medications to treat your Mental Health and/or Substance Use Disorder?

Have you been hospitalized within the last two (2) years with a Mental Health and/or Substance Use Disorder?

Are you currently receiving services with another provider?

Select all that apply

Are you currently receiving services with another provider?

INSURANCE INFORMATION

MCO

Medicaid ID

If unknown, input all zeros

SERVICE DISPOSITION

Additional Comments (If applicable, please describe any recent hospitalizations/treatment admissions, and all current symptoms/behaviors you have experienced in the last 30 days)

File Upload (If applicable, please upload any discharge and assessment information from Hospital/Treatment Facilities)

Referral & Screening Form