GLACIER HEALTH & DEVELOPMENT CENTER

2006 Bremo Road STE 101 - Richmond, VA 23226
(804) 918 1115
info@ghdc.org
(804) 944 2483

Who We Are
Outpatient Counseling Services
Forms Bank

GLACIER HEALTH & DEVELOPMENT CENTER

Who We Are
Outpatient Counseling Services
Forms Bank

© 2024 GLACIER HEALTH & DEVELOPMENT CENTER

Referral Form

Patient Demographics Information
Patient's Full Name
Patient's Preferred Name
Patient's Date of Birth

MonthDayYear
Date
Patient's Social Security Number
Patients Legal Sex
Patient's Gender/Pronouns
Patient or Guardian's Email Address
example@example.com
Patient or Guardian's Phone Number
Patient's Home Address
Patient's Legal Guardian(s)
Referral Source
Referral Person/Agency
Relationship to Client
Referral Phone Number
Email Address
example@example.com

Billing Information
Payment Type*
Is this a Medicaid plan?
Insurance Member ID Number
Insurance Group Number
Who is the insurance policy holder?
What is the policy holder's DOB?
Policy holder's legal sex?
Policy holder's relationship to the client?

Service Information
SERVICE REQUESTED: please state what service(s) you are requesting.

Family PsychotherapyIndividual PsychotherapyPsychological AssessmentConsultationClinical SupervisionPlay Based TherapyGroup PsychotherapyArt Based TherapyCare CoordinationCouples PsychotherapyNeurofeedback TrainingLife Coach ServicesCareer CounselingParent Support ServicesCounseling for AddictionAutism AssessmentOther
GOALS FOR SERVICE: Please state what you are hoping to be helped with as it pertains to your care and treatment
AVAILABILITY: Please provide a general summary of the days and times that the client is available for appointments
ADDITIONAL INFORMATION: Please include other information that might be beneficial to are scheduling with this person including information such as goals preference in service provider or other concerns related to care and treatment
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2006 BREMO ROAD STE 101 RICHMOND, VA 23226

info@GHDC.ORG

+1 (804) 918 1115

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