Referral/Screening Form
Date of Referral
*
/
Month
/
Day
Year
Date
Referral Type
*
Internal (Individuals currently receiving services with VFS)
External (Individuals not currently receiving services with VFS)
REFERRING PARTY
Name
*
First Name
Last Name
Suffix
Referring Agency
*
Please Select
Self-Referral
Virginia Family Services Staff
Community Partner
Parents/Guardian
Police Department
Behavioral Health Agency
Case Manager
Community Service Board/Behavioral Health Authority
Department of Corrections
Department of Juvenile Justice
Doctors Office
Hospital
Insurance Company
Nursing Home
School System
Probation/Parole Officer
Psychiatrist
Social Worker
Other
Position/Title
*
Phone Number
*
Please enter a valid phone number.
Email Address
INDIVIDUAL INFORMATION
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Age
SSN
*
Ethnicity
*
Please Select
Hispanic/Latino
American Indian/Alaskan Native
Asian
Black/African American
Hawaiian/Pacific Islander
Biracial
White/Caucasian
Middle Eastern
Assigned Gender
*
Please Select
Male
Female
Gender Identity
*
Please Select
N/A
Cisgender
Transgender
Non-binary
Genderqueer
Genderfluid
Do you have an alternative gender preference?
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Best time to Call
*
Please Select
9 AM-11 AM
12 PM-2 PM
3 PM-5 PM
6 PM- 8 PM
Anytime
Parent/Legal Guardian Name (If Applicable)
Parent/Legal Guardian Phone:
Please enter a valid phone number.
REQUESTED SERVICES
Requested Service(s)
*
Mental Health Skill-Building
Substance Use Partial Hospitalization ASAM 2.5
Substance Use Intensive Outpatient ASAM 2.1
Substance Use Outpatient Therapy/Alumni Group ASAM 1.0
Substance Use Case Management
Not sure which service to select
Are you currently receiving service(s) with Virginia Family Services?
*
Yes
No
If yes, which services(s)?
*
Enter N/A if not applicable
INSURANCE INFORMATION
MCO
*
Aetna Better Health
Anthem Health Keepers Plus
Humana
Medicaid (No MCO declared)
Molina Healthcare
Sentara Health
United Healthcare
Self-Payer
Medicaid ID
*
If unknown, input all zeros
PRESENTING CONCERNS
Please Select Presenting Concerns
*
Family Conflicts
Physical/Emotional Abuse
Sexual Abuse
Low Self-Esteem
Suicidal Ideation
Depression
Anxiety
Bipolar Disorder
Substance Use Disorder
Other
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)
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How did you hear about Virginia Family Services?
*
Please Select
Behavioral Health Agency
Case Manager
Community Partner
Community Services Board/Behavioral Health Authority
VA Dept. of Corrections
VA Dept. of Juvenile Justice
Doctor's Office
Hospital
Insurance Company/MCO
Nursing Facility
Assisted Living Facility
School System
Parent/Legal Guardian
Police Department
Probation/Parole Officer
Psychiatrist
Self-Referral
Social Worker
VFS Staff
Other
Submit
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