Health Connect America
personalized counseling services
FOR ADULTS, CHILDREN & FAMILIES AT - RISK

REFERRAL FORM
Please fill out form online —or— [download pdf] and fax to: 423-372-1205

* Required information.  

 Health Connect Clinic 460 West Main St., Abingdon, VA 24212, Office 866-412-2897, Fax 423-372-1205

Referring Agency Contact Information:   If Parent/Guardian Referral, who referred you: Today's Date:
Name/Agency:   
Relation to Client:      
Phone:    Please list any diagnosis and code:
Fax:   School Person Attends:
Email:   Is the person on any medications?  
**Have you informed the family that you are referring them for in-home services?

 
  Please list medications:

Client Name:*   Date of Birth:* (MM/DD/YYYY)
Social Security Number:      
Race:               Gender:  
Legal Status:        
Parent / Guardian:   Relationship:
Client Address:   City:  Zipcode: 
Home Phone Number:      
Work Phone Number:   Mobile Phone:
E-Mail:      

Please answer the following questions about the person you are referring:
What behaviors has the person been exhibiting? (drop in grades, decreased school performance/attendance, physical/sexual/emotional aggression, missing curfew, sexual inappropriateness, etc.)
 
Has the person experienced recent trauma that might have led to the above behaviors? (death of a loved one, divorce/break-up, sexual molestation,  etc.)
 
What services have been tried in the past?
 
Other relevant information about this referral:
 
   
     

top of pagetop