Referrals Referral Date Client Information First Name Last Name Date of Birth Gender Male Female School and Grade Services Requested Office-Based Outpatient School Based Home/Community Based Center Location Plaquemine, Louisiana Austin, Texas Houston, Texas San Antonio, Texas Louisiana Insurance Aetna Healthy Blue Louisiana Healthcare Connections United Healthcare Community Plan Other Medicaid Insurance Plan Texas Insurance Aetna Ambetter Amerigroup Blue Cross Blue Shield Community Health Choice/Beacon Community First Dell Children's (Amerigroup) Molina Healthcare Sendero Superior HealthPlan Texas Children's Healthplan United Health Care United Health Care Community Plan Other Medicaid Insurance Plan Client Contact Information (Client or Parent/Guardian Contact Information): Contact Number Is it OK to leave a message? Yes No Email Address: Address State: City Zip Code: For Children & Adolescents - Parent/Guardian Information Name of Parent or Legal Guardian Current Living Situation Home Group Home Foster Home Psychiatric Hospital Other Referral Source Information Complete this section so we can contact you after the referral is made. Name Mailing Address Phone Email Address How did you hear about The Village Life Center? Child/Adult Mental Health Information Known Current Medication & Dosage Current DSM-IV Diagnosis Reason for Referral for Treatment In your own words, describe the child/adult in need for mental health services. Describe specific behaviors the child/adult is exhibiting. Known Current Mental Health Symptoms Check all that apply. Hallucinations (describe below) Delusions Thought Disorder Bizarre (psychotic) Behavior (describe below) Anxiety/Nervousness Obsessive/Compulsive Phobias/Fears Depressed Mood Mood Swings Sleep Disturbance Irritability Anger/Temper Tantrums Hyperactivity Attention Deficit Eating Problems Elimination Problems Oppositional/Defiant to those in authority Antisocial/Delinquent Behavior/Conduct Disorder Over Sexualized Behavior Somatic Complaints with no Known Medical Cause Attachment Disorder (describe below) Other Describe
