Section 1: Service Selection
Choose which service is requested:
*
Community-based (home-based counseling, mentoring, parenting, supervised visitation etc..)
Outpatient (mental health counseling, substance abuse, etc...)
Therapeutic Services for Sexual Behavior Problems (Boundary Project & YSB Program)
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Section 2: Client Information
Client Name
*
First Name
Last Name
Parent / Legal Guardian (if applicable)
First Name
Last Name
Email
*
Client Birthday
*
-
Month
-
Day
Year
Phone Number
*
Client's Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Office Location
*
Please Select
Lynchburg - Brook Park Place - Forest
Lynchburg-Connecting point, Rivermont Ave
Harrisonburg
Virginia Beach
Fairfax
Roanoke
Bedford
Telehealth
Payment Method
*
Self-Pay
Insurance
Other (Ex. CSA, EBA, AMI, or other funded method)
Insurance Company & Number
*
Race & Gender
*
Open to Telehealth/Availability?
*
Yes
No
DSS/Caseworker (if applicable)
General Availability (Days/Times)
*
How can we help?
*
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Section 3: Referral Source
Referral Agency
*
Referral Name
*
Referral Address
*
Referral Phone Number
*
Please enter a valid phone number.
Referral Email Address
*
example@example.com
Referral Fax Number
*
Please enter a valid phone number.
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Section 4: Mental Health Services
Reason for Referral?
*
Prescribed Medications?
*
Previous or current receipt of mental health services (targeted case management, psychiatric care, individual therapy, etc) and/or involvement in the judicial system?
*
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Section 5: Presenting Problem
Describe reason for referral, including frequency, intensity, and duration of behaviors over the past 30 days.
Behaviors that put the individual at risk of out-of-home placement, in personal danger, substance use, and/or are significantly socially inappropriate:
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Behaviors that display deficits in social skill and/or dealing with authority, hyperactivity, poor impulse control, signs of extreme depression, signs of being marginally connected with reality:
*
History of Trauma (if applicable):
Sexualized behavior (if applicable):
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Section 6: CSA-Funded Referrals Only
Service(s) Requested:
*
Funder:
*
Relevant information pertaining to service request:
*
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