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)
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
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.
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
REQUESTED SERVICES
Requested Service(s)
*
Mental Health Skill-Building
Substance Use Partial Hospitalization ASAM 2.5
Substance Use Intensive Outpatient ASAM 2.1
Not sure which service to select
Are you currently receiving service(s) with Virginia Family Services?
*
Yes
No
If yes, which service(s)?
*
Mental Health Skill-Building
Substance Use Partial Hospitalization ASAM 2.5
Substance Use Intensive Outpatient ASAM 2.1
N/A
Have you ever been previously diagnosed with any of the following disorders?
*
Mental Health Disorder
Substance Use Disorder
Both
N/A (if not applicable)
Are you currently prescribed any medications to treat your Mental Health and/or Substance Use Disorder?
*
Yes, Prescribed medications
No, Not prescribed any medications
Have you been hospitalized within the last two (2) years with a Mental Health and/or Substance Use Disorder?
*
Mental Health Disorder
Substance Use Disorder
Both
N/A (if not applicable)
Are you currently receiving services with another provider?
*
N/A
Mobile Crisis Response
23-Hour Crisis Stabilization
Community Crisis Stabilization
Residential Crisis Stabilization
Mental Health Skills Building
Substance Use Intensive Outpatient
Substance Use Partial Hospitalization
Substance Use Inpatient Services
Select all that apply
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
SERVICE DISPOSITION
*
Request for Service Assessment
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)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: