Referral Form
SOS, Inc.
Page 1 of 2
Strengthening Our System, Inc.
464 Christiansburg Pike
Floyd Virginia 24091
540-585-4078
Fax 540-745-6710
Referral Form
Date: ______
Referral Source Information: ______
______
Referral Agency Name, Address, phone number
Individual Information: ______
______
Name, Address, phone number
Health Insurance Information:______
Health Insurance Name and Number (Medicaid or Private)
Individual Social Security Number:______Individual Date of Birth:______
Check one: ____ Male ____ Female Marital Status:______
Financial Information:
Source of Income:______Monthly Income:______
Disability Diagnosis: MH, DD
AxisI: ______
Axis II: ______
Axis III______
Axis IV______
Axis V______
Medical History and Medical concerns
______
Date of last physical:______
Physician Name and Address: ______
Medications: name, dosage, reason for prescription:
______
Parent, Guardian or LAR Information:______
______
Name, Address, phone, relationship
Presenting Needs/situation of the Individual______
______
______
______
Service Requested:Rate/hrHours per week
*Mental Health Support Services83.00/unit______
Intensive In-Home Services (MH)70.00______
Supportive In-Home DD Waiver19.85______
Service Facilitation (DD Waiver)rates vary______
Family/Care Giver Training (DD Waiver)46.86______
Therapeutic Consult (DD Waiver)55.13______
Crisis Stabilization (DD Waiver)81.00______
Start Date for Services______Anticipated End Date for Services ______
Funding Source for Services ______
What schedule for requested services does the case manager recommend? ______
Is the individual currently receiving any Case Management Services?
(Circle type of case management) MH DD
Name of Case Management Agency______
Name of Case Manager______
Case Manager Address______
Case Manager Phone Number ______
CSP Start and End date:______
Quarterly Review dates:______
Has the individual ever been hospitalized for psychiatric reasons? Circle one Yes No
If so, when and where was the most recent hospitalization?______
Is the individual currently receiving DD Waiver, or Community Rehabilitation Services?
Circle one: Yes No
If so, what type of Services? ______
Is the individual and/or their LAR willing to participate in services from this agency?
Circle one: Yes No
Items Below are for Agency use only:
Agency Recommendations for Services: ______
Disposition of the Referral: _____accepted _____denied ______pending
Signature of Person Completing Form Date
______