Client Referral Form – Day Treatment

There are several ways to complete this form. You can dowload  Client Referral Form (doc), print, complete information and 

Fax to: 434-239-0181

or

Mail to:
Jon Winder, Clinical Director

The Madeline Centre, Inc.
18697 Old Forest Rd
Lynchburg, VA 24502

Or complete the following  form online and submit.

    • Client Name:
    • Date of Referral:
    • Gender:
       M F
    • Age:
    • Date of Birth:
    • Race:
    • SSN#:
    • Medicaid #:
  4. Current Residence:
  5. Home Phone:
    • School:
    • Grade:
    • Parent / Guardian:
    • Relationship to Client:
    • Work Phone:
    • Cell Phone:
  3. Parent Address (if different from Current Residence above):
  1. Referring School include full mailing address:
    • School Staff:
    • Phone:
    • Email:
  3. Reason for Referral (include present concerns):
  4. Goals Outlined by Referring Agency:
  5. PRIORITY:
     Emergency High Average Low
  1. Indicate Services Requested by filling in the Cost Per Unit and the # of Units Requested
  2. Day Treatment:
    • Cost Per Unit:
    • Units Requested:
  3. In Home Therapist:
    • Cost Per Unit:
    • Units Requested:
  4. School Behavioral Therapist:
    • Cost Per Unit:
    • Units Requested:
  5. If Type of Service requested is "In Home Therapist," is client at risk of being taken out of the home? If Yes, explain:
  1. Billing Agency (include full mailing address and ATTN Line if necessary):

    The above named Billing Agency authorizes The Madeline Centre, Inc. to provide the listed services to the above named client and is responsible for payment of these services. The Madeline Centre, Inc. agrees to provide the listed services throughout the contract period unless a revised agreement is negotiated.
  2. Funding Source:
    •  FAPT/FAST Medicaid VJCC Other
    • Digital Signature of Referring Staff (Full Name):
    • Date:
    • Therapist Assigned: