Referral

KEY INDEPENDENT DEVELOPMENT SERVICES, LLC.

3212 Skipwith Road Suite 110
Henrico, VA. 23294

(804) 716-4464 Office
(804) 447-1591 Fax

______________________________________________________________________

Type of Referral:

• Mental Health Skill Building
• Intensive In-Home Services
• Substance Abuse
• DD Waiver Residential
• DD Waiver Day Support

Date of Referral

Identifying Information - Method of Screening:

• Telephone
• Written
• Face to Face

Past/Currently Receive Services?

• Yes
• No

Date:

Checked with Insurance Company?

• Yes
• No

Name *

DOB:

Race:

Gender

• female
• male

Medicaid #

HMO or Other Insurance Name and #:

Address:

Telephone:

Parent/Authorized Representative Name:

Telephone:

Address:

Referral Source: *

Telephone:

Current Behavioral Problems: (please describe behaviors that place the person at risk out-of-home placement or a psychiatric hospitalization, homeless, or interaction with the legal system include onset and duration of behaviors and frequency along with duration of behaviors)

Has this person ever been hospitalized for psychiatric services?

• Yes
• No

Within the past 12 months?

• Yes
• No

Over 12 months ago?

• Yes
• No

Name of Hospital/s: *

Dates of Service:

Received Crisis Stabilization? Residential/Nonresidential

• Yes
• No

Date/Place of Service:

Intensive Community Treatment?

• Yes
• No

Date/Place of Service:

Does this person have a psychiatrist?

• Yes
• No

If so, Name of Psychiatrist:

Address:

Telephone Number?

Fax Number:

Does the person take prescribed psychiatric medications?

• Yes
• No

Name and Location of pharmacy:

Pharmacy's telephone number:

Fax Number:

If so, please list medications and dosage:

Medical Problems:

Screening recommendation and disposition plan:

• Based on the above information and information obtained, applicant is appropriate for the program and will be admitted.
• Based on the above information and information obtained, applicant is not appropriate for services and will be recommended for Appropriate services.

Recommendations are:

If applicant is appropriate for services, the assessment is scheduled for:

Enter date and time here

Single Line Text

Name and Title of person completing the referral:

Please include the date here

Signature:

Date:

Submit