Professional Referral — Meridian Behavioral Consulting through EverLoom
Complete this referral after the family agrees to be contacted; we’ll reach out within 2–3 business days.
About You (Referring Professional)
Full Name
*
First Name
Middle Name
Last Name
Credentials / Title
*
Profession
*
Physician / Pediatrician
Nurse Practitioner / PA
Therapist (SLP, OT, PT)
Mental Health Professional
Teacher / Educator
School Staff (counselor, psychologist, administrator)
Other
Organization / Practice / School Name
*
Work Email
*
example@example.com
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Please Select
Email
Phone
No follow-up needed
Receive an Update After Family Contact
Yes, with family's permission
No
Family & Child Information
Parent/Caregiver Full Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Parent
Guardian
Grandparent
Foster parent
Other
Caregiver Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Caregiver Email
example@example.com
Preferred Contact Method
Please Select
Phone call
Text
Email
Child's First Name
*
Child's Age
*
City/County of Residence
Please Select
Charlottesville
Albemarle County
Other
Primary Language Spoken at Home
Interpreter Needed?
Yes
No
Reason for Referral
Primary concerns
*
Aggression
Self-injury
Tantrums / meltdowns
Elopement / running
Difficulty with transitions or routines
Communication challenges
Sleep challenges
Feeding / mealtime challenges
Toileting
Social skills
Daily living skills
Caregiver stress / need for parenting strategies
Other
Brief description of concerns and what prompted this referral
*
Services recommended
*
Caregiver coaching
Behavioral intervention / individual support plan
Home routine support
Not sure — consultation recommended
Known diagnoses (if any and if the family has shared permission)
Urgency
*
Routine
Soon (within a few weeks)
Priority — family is struggling significantly
Anything else we should know
Consent & Acknowledgment
Acknowledgment of family/guardian awareness and contact permission
*
Family/guardian is aware of this referral and agrees to be contacted by EverLoom / Meridian Behavioral Consulting
Emergency limitation acknowledgment
*
This referral is not an emergency service; if a child is in immediate danger, I will contact 911 or the appropriate crisis services
Referring professional e-signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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