Referral / Intake Form
Please provide as much information as possible
Is this referral for you or another person?
*
Self-referral
Another person
What is your relationship to the person being referred?
Ex. (Mother, MHSB worker, Case Manager, Peer support, Friend, etc.)
Referring Agency
Contact Name
Name of person making the referral
Contact Phone Number
Your Phone not the referral
Extension
Email
example@example.com
Patient Information
Client Name
*
First Name
Middle Name
Last Name
Suffix
Today's Date
-
Month
-
Day
Year
Date
Client Date of Birth
*
/
Month
/
Day
Year
Date
Age
Client Phone Number
*
Client Email
example@example.com
Current Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Reason for No Address
Unknown
Homeless
Gender
*
Male
Female
Transgender
Non-binary
Other
Other:
Gender
SSN
NO SSN
Unknown
Race
*
Decline to answer
Caucasian
Black or African American
Asian
American Indian or Alaska Native
Bi-racial
Middle-Eastern
Other
Other:
Race
Marital Status
*
Single
Divorced
Married
Widowed
Co-habitating (yrs.)-not married
Other
Other:
Marital Status
Employment status:
Full-time
Part-time
Unemployed
Volunteering
Disabled
Retired
Client Insurance
*
No Insurance
Medicaid
Medicare
Commerical / Private
Medicaid ID
12-Digit ID
NO Medicaid ID
Unknown
Medicaid MCO
Anthem HK+
Aetna BH of VA
Molina Complete Care
Magellan (Straight Medicaid)
Optima / Sentara
United HealthCare
Virginia Premier
Select MCO
Medicare Policy Info
Other Policy Info
Insurance Card(s)
Browse Files
Upload picture of Insurance ID cards
Cancel
of
Take Photo of ID Card
Emergency Contact
Name / Relationship
EC Phone Number
Emergency Contact Address (if available)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Data
Presenting Problems - check all that apply
*
Do you have upcoming Court / PO apts.?
*
Yes
No
Probation / Court details
Upcoming Court / PO Apts.
PO / Attorney - Contact
Are you prescribed / taking any current medications?
*
Yes
No
Current Medications
*
Do you have any allergies?
Food
Environmental
Medication
No allergies are known
Do hou have any of the following conditions:
I HAVE NONE OF THESE
Asthma
Cardiovascular Disease
Diabetes Mellitus
Tuberculosis
Diabetes
HIV
Hepatitis A/B/C
Depression
Anxiety
Drug/Alcohol Addiction
Cancer
Dementia / Alzheimer's
TB
High Cholesterol
High Blood Pressure (Hypertension)
Chronic Pain
COPD
Seizures / Neurological
Liver Prolems
Glaucoma
High Cholesterol
Epilepsy
Sleep problems / Insomnia
Kidney Problems
Please describe Existing Medical Problems/Conditions
Any further details or other medical issues not mentioned above
Please describe any previous hospitalizations / Surgeries:
Provide the reason and treatment
Does your Family have a history of Illnesses?
NO - NONE OF THESE
Asthma
Cardiovascular Disease
Diabetes Mellitus
Hypertension
Tuberculosis
Diabetes
HIV
STD's
Depression
Anxiety
Drug/Alcohol Addiction
Cancer
Dementia / Alzheimer's
Alzheim
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