Serenity Counseling Services of Virginia - New Client Referral Form

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Please complete this referral and a representative of our team will reach out within 2 business days (does not include weekends or holidays). For immediate assistance or questions, please contact our office at 804-569-2100.

Email *

Client Full Name (Include preferred name in parentheses please) *

Date of Birth *

YYYY

Gender
*

Male

Female

Other:

Phone Number *

Address *

Email Address *

Which program are you seeking? *

Intensive In Home Services (Chidlren ages 5-21)

Mental Health Skill Building Services (Adults ages 18 and up)

Residential Crisis Stabilization (Adults ages 18 and up)

Required

Insurance Provider *

Self Pay

Aetna Better Health of Virginia - Medicaid

Anthem Healthkeepers Plus - Medicaid

Molina Complete Care - Medicaid

Optima - Medicaid

Sentara - Medicaid

United Healthcare - Medicaid (we are not currently in network with this MCO)

Humana Medicaid

Medicaid of Virginia (straight Medicaid)

Other:

Insurance / 12 Digit Medicaid ID *

If under 18, parent/guardian name: (First and Last)

Current Diagnosis, if any: *

Reason for Referral: (please include information about recent symptoms/behaviors that may be of concern) *

When is placement needed?
*

History of or current substance use/abuse? (Please include last use for each substance and any previous substance abuse treatment) *

Please list all medications that the individual is currently taking: *

Please list any chronic or short-term medical diagnoses the individual has. If none, please write n/a *

Are there any physical limitations that would cause challenges for the client to go up and down stairs? Please explain.
*

Previous Mental Health Hospitalizations? (please include month/year and reason for hospitalization) *

Please list any other providers or professionals that would be helpful to coordinate with throughout services: *

Please list Probation/Parole Officer contact information, if applicable.

Is this individual a registered sex offender that will need to report their location to the Virginia State Police?
*

Yes

Are there any active warrants for this individual?
*

Yes

Referred By: (please include your name and phone number) *

How did you hear about Serenity Counseling Services of Virginia? *

Send me a copy of my responses.

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