REFERRAL FORM
Please fill out this form and either bring it, e-mail it, mail it or fax it
Referral Form 09/02/14
Therapy Session-
Time Availability
(check all that
apply)
Clinic where you prefer to receive services (please check):
□ Calvert 55 Stoakley Rd. Suite 7 (2
nd
floor) Prince Frederick, MD 20678
Phone: 240-296-6066 Fax: 240-383-3435 Email: IRC@Vesta.org
□ Lexington Park 46940 S Shangri La Dr Suite 15, Lexington Park, MD 20653
Phone: 240-296-6050 Fax: 301-263-7304 Email: IRCSoMD@Vesta.org
□ Forestville 3900 Forestville Road Forestville, MD 20747
Phone:240-296-6066 Fax: 240-383-3435 Email: IRC@Vesta.org
□ Odenton 1202 Annapolis Road, Suite F Odenton, MD 21113
Phone: 443-396-3110 Fax: 240-383-3435 Email: IRC@Vesta.org
□ Germantown 20410 Observation Dr. Suite 108, Germantown, MD 20876
Phone: 240-296-5858 Fax: 240-383-3435 Email: IRC@Vesta.org
□ Silver Spring 8737 Colesville Rd. Suite 700, Silver Spring, MD 20910
Phone: 240-296-5858 Fax: 240-383-3435 Email: IRC@Vesta.org
□ Lanham 9301 Annapolis Rd Lanham, MD 20706
Phone: 240-296-6323 Fax: 240-383-3435 Email: IRC@Vesta.org
□ Waldorf 22 Industrial Park Drive Suite A, Waldorf MD 20602
Phone: 240-296-6050 Fax: 301-263-7304 Email: IRCSoMD@Vesta.org
Intakes in Germantown are walk- in on Tuesdays from 10am to 1:00pm and 1:30pm to 4:30pm ONLY
Intakes in Silver Spring are walk- in on Wednesdays from 10am to 1:00pm and 1:30pm to 4:30pm ONLY
Referral Source Information Self □ Date: ____________________
Referral Source (Name):___________________________________ Agency: _______________________________________
Address: ______________________________________________________________ City: ____________________
County: ______ State: ____ Zip Code: ________ Phone: ______________________ Fax: _____________________
Client Information Marital Status________________ Race/Ethnicity_____________ Gender: M □ F □
Client’s Name: ___________________________________________ DOB: _________________ SSN:_______________
Address: __________________________________________________ Email Address: ________________________________
City: _______________ County: _____ State: ___ Zip Code: _______ Phone: ________________ Cell Phone: _____________
Native Language (If other than English): ______________ Does Client Speak English? Yes □ No □
Caretaker Name or Emergency Contact: __________________________________ Daytime Phone: _____________________
Relationship to client: Parent □ / Foster parent □ / Legal guardian □ / Social Worker □ / Case Manager □ / Other ____________
Does Caretaker Speak English? Yes □ No □
Reason(s) for Referral (check all that apply)
□ Next hearing date (if known)
□ PRP (Germantown, Odenton, Lanham and Forestville offices ONLY)
□ Discharged from inpatient facility
□ Supported Housing (Germantown, Odenton and Lanham offices ONLY)
□ Other____________________________
Payment Information: □ Medicaid □ Medicare □ Medicaid/Medicare □ Private Insurance □ Self Pay
Medicaid#: ________________________________________ Medicare#: ________________________________________
Name of Private Insurance: ___________________________ Person Insured (Subscriber): __________________________
Client’s ID: ________________________________________ Group#:___________________________________________
Brief Description of Problem. (Use a separate sheet if necessary).
Please forward relevant medical & behavioral information, court orders, reports from
previous evaluations, social summaries, if discharge from inpatient facility-attach copy of
after care plan and discharge summary, etc.
Current Diagnosis Information: ______________________________________________
________________________________________________________________________________________________________
Current medications: ______________________________________________________________________________________
________________________________________________________________________________________________________
Do you require ADA (American with Disabilities Act of 1990) accommodations? If yes, explain: _________________________
____________________________________________________________________________________________________
VESTA ONLY
Staff receiving this referral: ___________________________________ Comments: ________________________________________
