VOA Care Collective (VCC) Behavioral Health Referral Form

VOA Care Collective (VCC) Behavioral Health Referral Form

Referral form for Volunteers of America Eastern Washington and Northern Idaho. Complete all requested referral, participant, clinical, records, and internal triage information.
Referral Source
Date of Referral

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Referring Agency / Program
Referring Contact Name and Role

First NameMiddle NameLast Name
Phone / Email
Relationship to Participant
Best Way / Time for VCC to Reach Referrer
Participant Information & Outreach Preferences
Legal Name

First NameMiddle NameLast Name
Preferred Name / Pronouns
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
May VCC leave a voicemail?
Email
example@example.com
Current Address / Location

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Language, Interpreter, or Accessibility Needs

0/255
Insurance / Payer (if known)
Parent / Legal Guardian (if applicable)

First NameMiddle NameLast Name
Participant Awareness and Outreach
Is the Participant Aware of This Referral?
Does the Participant Agree to Be Contacted by VCC?
Preferred Contact Method
Best Days / Times to Contact
Any Outreach or Engagement Considerations?
Reason for Referral, Goals, Services, and Triage
Why is the participant interested in services at VCC?
Participant’s stated goals (in their own words, if possible)
How long have the current concerns or needs been present?
Barriers that may affect engagement

Other
Services Requested / Routing
Requested VCC service(s)

Other
Referral priority
Reason for requested priority
Safety and Clinical Triage Flags

Screening Item

Rows	Yes	No	Unknown	Notes / date if known
Current suicidal thoughts or self-harm concern
Suicide attempt or self-harm in the past 12 months
Current thoughts or credible risk of harming others
Recent overdose or high overdose risk
Risk of significant alcohol/drug withdrawal
Severe psychiatric symptoms affecting immediate safety or functioning
Domestic/interpersonal violence or unsafe living situation
Medical concern that may require urgent evaluation

Relevant Care Information
Current behavioral health or substance use providers
Relevant diagnoses or prior treatment history
Current medications relevant to this referral
Primary medical provider and significant medical needs
Other services currently involved

Other
Recent hospitalization, crisis, detox, or higher level of care
Information Sharing & Supporting Documents
Release/consent status
Helpful records attached, if available

Other
File Upload

Cancelof
Additional infromation VCC should know

Should be Empty:

VOA Care Collective (VCC) Behavioral Health Referral Form

Referral Source

Participant Information & Outreach Preferences

Participant Awareness and Outreach

Reason for Referral, Goals, Services, and Triage

Services Requested / Routing

Safety and Clinical Triage Flags

Relevant Care Information

Information Sharing & Supporting Documents

For VCC internal use only - intake and triage