In-Home Service Referral

Client Information*

First NameLast Name

Date of Birth*

MonthDayYear

Gender*

Marital status*

PLEASE NOTE: In-home services are only offered on Long Island, Queens and Westchester County.*

Client Street Address

Client Street Address Line 2

CityState

Zip Code

Phone Number*

Type of number

Secondary Phone Number

Type of number

Email*

example@example.com

Primary Language *

Type of Housing*

Requested Service Setting *

In-home/ in-person**Please note in-home availability may be limited based on availability of our practitioners in your area at the time of request.Telehealth

If in-home services are not available does the individual agree to telehealth services?*

YesNoUnknown

Are there any specific days or times being requested for appointments?

Primary insurance*

Insurance ID #:*

Secondary Insurance (if applicable)

Insurance Carrier and Insurance ID #

Previously diagnosed mental health and/or medical conditions:

History or present concerns regarding any of the following:

Living Conditions?*

YesNoUnknown

Substance Abuse*

YesNoUnknown

Violence or DV?*

YesNoUnknown

Any Firearms/ Weapons in the home?*

YesNoUnknown

Legal Problems?*

YesNoUnknown

Any pets?*

YesNoUnknown

Risk of losing housing?*

YesNoUnknown

Is anyone residing in the home a registered sex offender?*

YesNoUnknown

If you answered yes to any of the questions above, please explain.

Primary contact person to schedule the appointment (If other than the client)?

First NameLast Name

Relationship to Client:

Contact Number

Is this person also the emergency contact?

Referral Source*

First NameLast Name & Title

Email

example@example.com

Phone Number*

Fax Number

Agency Name:*

Address

Street Address

Street

CityState

Zip Code

Reason for the Referral : *

If applicable, please attach any recent psychosocial or psychiatric assessments and/or discharge reports.

*If you are an inpatient mental health provider, please include a recent psychiatric evaluation and/or psychosocial.

COMPLETED REFERRALS CAN BE SENT TO

FAX: 1-516-418-5377 OR EMAIL: INFO@VCOFNY.ORG

Disclaimer: By submitting this form on behalf of a client, I confirm that the client is aware of the referral being made on their behalf. It is also understood by the client that there may be insurance-related charges or copayments associated with the services provided, as determined by the client's insurance provider. The client is also aware that Visiting Counselors accepts Medicaid as a secondary insurance, as well as many supplement plans. However, it is the client's responsibility to verify whether their specific supplement plan covers copayments and/or potential deductibles. If the client has any questions regarding their insurance coverage, they are advised to contact their insurance provider. Furthermore, clients may also contact Visiting Counselors to determine or verify whether their insurance is accepted by calling our office at (516) 698-5511.

I acknowledge the above disclaimer regarding possible insurance-related charges.

Would you like us to confirm via email once a social worker has been assigned to working with this individual?*

YesNo