Each One Teach One, LLC

Each One Teach One, LLC

"Helping One Family at a Time"
Phone: (757)-937-7636
Fax: (757)-240-4380
Email: Info@eachonesteachone.org
This form is to be completed and signed before the initial assessment.
Date Referral Received:
Referral Source Name:
Referral Source Phone:
Format: (000) 000-0000.
Referral Source Email Address:
Format: Email Address .
I HAVE DISCUSSED THE SERVICES I BELIEVE ARE BEST WITH THE REFERRED CLIENT AND/OR GUARDIAN BELOW AND THEY HAVE AGREED IF AND ONCE APPROVED TO RECEIVE SERVICES:
Name:
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age:
Phone Number:
Format: (000) 000-0000.
Gender:
Parent/ Legal Guardian: (if minor)
Address:
Medicaid Number:
Insurance Company:
Emergency Contact:
Relationship to Emer Contact:
Emer Contact Phone:
Format: (000) 000-0000.
Primary Care Physician / Facility:
MEDICAID STATUS / INSURANCE INFORMATION
Services of Interest (MHSB, IIH, Therapy, Peer Support, Mentoring, Group Home, etc..)
PRESENTING PROBLEMS AND NEEDS:
Previous Diagnosis:
Previous Medication
Screening Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Start Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
FOR OFFICE USE ONLY
Referral admitted into CSS Services:
If Yes, Date of Admission:
Referred to other services for assessment:
Disposition:
SCREENING COMPLETED BY:
SIGNATURE:
This referral form collects Protected Health Information (PHI) protected under HIPAA. Information submitted is encrypted, accessible only to authorized staff, and used solely to process your referral. We never sell or share health information. Questions? Call 757-936-7636 or email info@eachonesteachone.org.
Should be Empty:

PRESENTING PROBLEMS AND NEEDS:

FOR OFFICE USE ONLY