NOVA Pre-Screening Form

NOVA Pre-Screening Form

Welcome to NOVA Community Services!

We are here to support individuals and families who are feeling overwhelmed by life’s challenges. If you have active Virginia Medicaid, you may qualify for short-term support designed to help you manage stress and regain stability during difficult moments. Our counselors work alongside you over a 5-day support period to help address the stressors impacting your daily life. This may include challenges related to housing concerns, food access, employment or job searches, transportation, nutrition, and other everyday needs that can affect your emotional well-being. Our goal is to help you feel supported, connected, and informed by identifying available community resources and assisting you in taking the next steps toward relief and stability. This form helps us understand how to best support you. Your answers are private and used only to connect you with help. You can skip any question you’re not comfortable answering and our team will follow-up with you.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Do you currently have Medicaid in the state of Virginia?*

YesNo
What is your date of birth. (Note: This information is needed to check your VA Medicaid eligibility and determine which services you may qualify for.*
Enter your Date of Birth in Month-Day-Year format
In the past 90 days, have you had thoughts about not wanting to be here anymore?

YesNo
Do you ever feel like others might be better off without you?

YesNo
Are you worried about having a safe and stable place to live right now?

YesNo
Are you feeling stressed about work, income, or being able to support yourself or your family?

YesNo
How often have you worried about having enough food for yourself or your family?

NeverSometimesOftenAlmost Always
How often do you feel stuck, overwhelmed, or dissatisfied with life right now?

NeverSometimesOftenAlmost Always
Are you or your family currently facing challenges you would like help with?

YesNo
How many people live in your household (including yourself)?
Number of Adults
Number of Children under age 18
Is there anything else you’d like us to know about your situation or how we can support you?
Important Information

The information provided on this form is used solely to pre-screen potential clients for services with NOVA Community Services. Submission of this form does not guarantee eligibility for services.

If you are identified as a potential candidate, you will be contacted by phone by a member of our assessment team or one of our community partners, which may include Accomplished Counseling Services, to complete the next steps in the process.

Please ensure your contact information is accurate so we may reach you if additional information is needed.
If you are in immediate danger or feel unsafe right now, please call 911 or the Suicide & Crisis Lifeline at 988.If you select that you’re struggling, our team will follow up as quickly as possible.
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