Phone: (304) 941-6256 Fax: (304) 553-0379 Provider #: 0030217852

90 MacCorkle Ave SW, Ste 201, So. Charleston, WV 25303

REFERRAL

Referrer Info

Referred by:	Phone #:

DHHR Self Parent/Guardian Other:

(please specify)

Consumer Info

Consumer Name:	Phone #:

Address:	County:

DOB:	Age:	Gender:	SSN:

School:	Grade:

Who does consumer live with?

Why is the consumer being referred?

Presenting Problems (check all that apply): Behavior problems Truancy Anxiety Depression Self-harm Parent-child conflict Violence/aggression Drug use Other:

Requested Services
Medically Necessary:	*Socially Necessary:
Psychological Evaluation	CAPS Assessment
Individual Therapy	Other:
Family Therapy	* Please attach an ASO letter for these services
Other:
Legal Info

Consumer’s Legal Guardian(s):	Phone #:

For youth not in their parents’ custody:

Parent Name:	Phone #:

Parent Name:	Phone #:

Open CPS case? - Yes No	Open YS case? - Yes No

Court involvement? - Yes No	Next court date:

If yes, then please list charges:

Insurance Info

Insurance Name:	Insurance Phone #:

Member ID #:	Group #:

Policy Holder Name:	DOB:

Private Pay