Appointment Request/Referral Form
Client Name
*
First Name
Last Name
Age
*
Client Date of Birth
*
-
Month
-
Day
Year
Date
Person submitting form:
*
Client Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Service Type Requested
*
Individual Counseling
Marriage/Couples
Medication Management
Trauma
Alcohol/Drug
Grief/Loss
Other
Service
Individual Counseling
Marriage/Coupls
Medication Management
Trauma
Alcohol/Drug
Grief/Loss
Other
Select all that apply
What is your availability? Specific day/time?
Are there any legal issues you are involved in?
*
No
Yes
Legal Situation - check all that apply
Currently on parole / probation
Arrest(s) not substance-related
Arrest(s) substance-related
Court ordered in place
Jail/prison time
Other
Do you have insurance?
*
Yes
No
Insurance - Name & Policy # / Member ID
*
Please also list the member ID if you know it.
Insurance Card - front & back
Browse Files
Drag and drop files here
Choose a file
Cancel
of
No Insurance - If you have no insurance please list the number of people in your household and average monthly income for our sliding scale
*
Special Request - Do you have a preference of male or female? Telehealth/face-to-face? Therapist preference?
Anything specific you would like for us to know about you?
How did year hear about or who referred you to Blue Ridge Hope?
Submit
Should be Empty: