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Referral Submission

Please complete this referral form and one of our skilled professionals will be in contact with you as soon as possible.

We are here to support you, every step of the way

Phone

804-355-1990

Email

info@focusinc.net.in

Date of referral

Services Requested

Referred by:

Phone

Agency

Fax

If self referred, how did you hear about us?

Prospective Client First name

Gender

Medicaid Number

Prospective Client Last Name

Parent/Guardian First & Last Name

Phone

Date of Birth

Parent/Guardian Phone Number

Address

Reason(s) for referral (Please select as many as needed)

Social/Communication Challenges

Substance Abuse

Medication Management

Property Destruction

Violence in school and community

Behavioral health issues At-risk youth

Criminal history

Mental health diagnosis

Suicidal and homicidal tendencies

CPS involvement

Acute hospitalization

Homelessness

Half-way house involvement

Sexual abuse

Psychotropic medication

Learn early-stage relapse management

Develop coping strategies

Establish or re-establish psychosocial support

Address problems related to social, psychological and emotional well-being

Other

If other, please explain

Has this client received services in the past? *

Yes

No

Thank you for taking the time to complete this form. One of our professionals will be in contact with you shortly!

For official use only

STATUS

Medicaid Insurances We Accept

Aetna

UHC/Optum

Anthem

Sentara

Molina

FOCUS Inc.

804-355-1990

info@focusinc.net.in

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