Client Referral Form – Intensive In-Home

Please fill out FORM BELOW.

Or you can download  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

Begin here to complete the form online,  fill out and SEND.

    • 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 Agency include full mailing address:
    • Worker:
    • Phone:
    • Email:
  3. Reason for Referral (include present concerns):
  4. Goals Outlined by Referring Agency:
  5. PRIORITY:
     Emergency High Average Low
    • Is client at risk of removal from the home?
       Yes No  Don't Know
      Comment:
    • Has client been seen in outpatient counseling?
       Yes No Don't Know
      Comment:
    • Has client been in any mental health treatment in the last 6 months?
       Yes No Don't Know
      Comment:
  1. (For general practitioners, psychiatrists, psychologists, LPC’s and LCSW’s):
  2. According to my evaluation I certify that client is in need of intensive in home therapy and recommend out of home placement unless there is a change in behavior and/or mental health condition.

    • Signature:

    • Title:
    • Digital Signature of Referring Worker (Full Name):
    • Date:
    • Therapist Assigned: