Medication Management Referral Form
This form is for people seeking medication management appointments with Atlantic Counseling Group. Please fill out the information below for the person in need of the appointment.*We can only provide tele-health services for residents of Virginia* A member of the administrative team will contact you within 3 BUSINESS DAYS.
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Name (First, Middle Initial, Last) *
I reside in the state of Virginia *
Required
Date of Birth *
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DD
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YYYY
Are these medication management appointments needed to be discharged from a medical or mental health facility? *
If you answered yes to the previous question, please do not fill out this form. Unfortunately, because these appointments are needed to be discharged from a facility, ACG cannot provide the level of care needed and cannot schedule you.
Are you scheduling for ADHD medication management? *
If yes, do you have a current ADHD diagnosis, have had a Psychological test, or are already taking medication for ADHD? *
If you answered yes to the previous question, please explain:
Are you currently under the care of a therapist? *
If you answered yes to the previous question, please provide their name:
Have you been discharged from the hospital for mental health reasons in the past year? *
If you answered yes to the previous question, please give the dates of your hospitalization and discharge date:
Are the medication management appointments you are scheduling court mandated? *
Are the medication management appointments you are scheduling needed to obtain any disability claims or paperwork? *
If you answered yes to the previous question, please note that you must see a clinician for at least two months before your paperwork will be signed. *
Required
Primary Insurance Company *
Referral Source (if any)
Person to contact regarding scheduling (if different than client):
Best phone number to reach you: *
Best email address to reach you: *
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