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Strategic Therapy Associates - Self Referral Form
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* Indicates required question
Email
*
Your email
Service Region:
*
Choose
Danville
Farmville
Galax
Lynchburg
Martinsville
Norfolk
Richmond
Roanoke
Client's Full Name:
*
Your answer
Client's Date of Birth:
*
MM
/
DD
/
YYYY
Client's Social Security Number:
Your answer
Client's Gender:
*
Your answer
Client's Race:
*
Your answer
Client's Primary Care Physician: (Agency name & physician name)
Your answer
Community Services Board Case Manager: (Agency name and case manager name)
Your answer
Parent/Guardian Name, if under 18:
Your answer
Parent/Guardian Relationship to Client, if under 18:
Your answer
Foster Parent Name & Number, if applicable:
Your answer
Parent/Guardian or Adult Client Email:
(*Required for Patient Portal)
Your answer
Full Home Address: (City, State & Zip Code)
*
Your answer
Cell Phone #:
*
Your answer
Home Phone #:
Your answer
Services Requested:
*
Casey Life Skills
Evidence-Based Brief Strategic Family Therapy (BSFT)
Evidence-Based Functional Family Therapy (FFT)
Evidence-Based Trauma-Focused Cognitive Behavior Therapy (TF-CBT)
Home-Based Counseling
Intensive In-Home Counseling
Mental Health Skill-Building
Outpatient Counseling (Individual)
Outpatient Counseling (Family)
Parent Aide Services
Parent Reunification
Substance Abuse Counseling
Substance Abuse Evaluation
Substance Abuse Relapse Prevention
Therapeutic Mentoring
Other:
Required
Reason for Referral: (List specific behaviors and previous interventions)
*
Your answer
Funding:
*
Choose
Sentara Health Plan
Virginia Medicaid
Aetna Commercial
Anthem Commercial
Cigna/Evernorth Commercial
Optima Commercial
Piedmont Community Health Plan
Tricare Select
United Healthcare Commercial
AMI Kids
EBA
CSA
CSB
Other state contracted funding
Medicaid Policy Number: (12 digits)
*
Your answer
Medicaid MCO:
*
Choose
Aetna Better Health
Anthem, Beacon, Carelon
Optima
United Health Care
Virginia Premier
Magellan BHSA
Unknown
Commercial Insurance: (*Must list if in addition to Medicaid)
Choose
Aetna Commercial Plan
Anthem of Virginia Commercial Plan
Cigna, Evernorth Commercial Plan
Optima Commercial Plan
PCHP Commercial Plan
United Health Care Commercial Plan
Commercial Insurance Number:
Your answer
Commercial Subscriber Name:
Your answer
Commercial Subscriber Date of Birth:
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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