Referral Form

First name*

Last name*

Email*

Phone*

Address

Which program(s) are you interested in?

Applied Behavioral Analysis

ADOS Testing

Substance Abuse Intensive Outpatient

Traditional Outpatient Therapy

Mental Health Intensive Outpatient

Description of Presenting Issues

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/ Guardian Email

Parent/Guardian Phone Number

Insurance Provider

Policy ID

Group Number

Please Select Coverage Type

Medicaid

Medicare

Commercial

Federal (Tricare)

Self Pay

Subscriber First Name

Subscriber Last Name

Subscriber Date of Birth

Relationship to Subscriber

Self

Spouse

Child

Other

Front & Back of Insurance Card

I authorize Civitas Health Services, Inc., to contact me regarding this referral form.

Where Change is Possible!

The mission of Civitas Health Services, Inc. (CHS) is to change the culture of behavioral health through a higher standard of service delivery.

804.737.3917

Civitas Health Services, Inc.

Licensed by the State of Virginia Department of Behavioral Health and Developmental Services.

Policy

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