VOLUNTEER COUNSELING SERVICE – INTAKE - FOR STAFF …
Fax form to VCS at (845) 634-7839 or email to ilaidlaw@vcs-
CLIENT DATA: (All information is confidential) Please print clearly
Name:
Social Security #: Date of Birth:
Phone #:
Language fluency (check all that apply): ( English ( Spanish ( Creole
Address (Street & Number):
Address (City, State, Zip):
Parent / guardian name (if applicable):
Language fluency (check all that apply): ( English ( Spanish ( Creole
School name (if child / adolescent):
Reason for Referral:
Plan for transportation to appointment in place (required)? I I Yes I I No
Details:
REFERRING AGENCY:
Contact Name:
Agency Name:
Contact Phone #: Contact Fax#:
Contact Email Address:
INSURANCE INFORMATION:
Medicaid ο Yes ο No Policy Number:
Medicaid Managed Care: ο Fidelis ο Affinity
ο MVP ο Empire BCBS HealthPlus
ο Affinity ο Healthfirst
ο United Healthcare ο Wellcare
ο Crystal Run Healthplan ο Aetna
Policy Number:
Family Health Plus? ο Yes ο No FHP#:
Other Insurance ο Yes ο No
Insurance Name: Insurance ID#:
Phone # (from back of the id card): Group #
Insured’s Name: Insured’s DOB:
Relationship to Client:
Insured’s Address:
Insured’s Social Security #:
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VCS MENTAL HEALTH CLINIC
Referral for Services
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