SUBSTANCE USE SERVICES FACE-SHEET
Mandatory Information
Referring Agency
*
Contact Name
*
Telephone #
*
Date of Contact
*
/
Month
/
Day
Year
Date
Internal Referral Source
Client Name: First
*
Client Name: Middle
*
Client Name: Last
*
DOB
*
Age
*
Gender
*
SS#
*
Marital Status
*
Race
*
Religious Preference
*
Primary Address
*
Client Primary Contact Number
*
OK to leave message?
*
Client Email Address
*
OK to leave message?
*
Method(s) of Screening (select all that apply)
*
Telephone
Face to Face
Hospital Docs
Relative / Friend Request
Presenting Needs/ Reason for Requesting Services
*
Insurance
Medicare
Medicare Policy ID
Insurance
*
Medicaid
Medicaid ID
*
Medicaid Line/MCO: Anthem, Aetna Better Health, Magellan Behavioral Health, Molina Complete Care, Optima/Sentara, Optum, Virginia Premier Med 4.0, or VA Premier CCCP
*
Other Insurance
Other
Other Insurance - Insurance Company
Other Insurance - Policy ID
Emergency Contact Name
*
Emergency Contact Address
*
Emergency Contact Numbers: Mobile
*
Home
*
Office
*
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