Make A Referral

Now accepting new referrals. Let us partner with you in providing exceptional care.

For Use by CSB Support Coordinators

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1Referral Information

2Individual Information

3Referral Purpose

4Diagnosis and Current Services

5Supporting Documentation Checklist

6Preview & Submit

Diagnosis of Below

Referral Information

Date of Referral *

Referring CSB *

Support Coordinator Name *

Phone *

Email *

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Individual Information

Name Of Individual *

DOB *

SSN *

Medicaid *

Legal Guardian (if applicable)

Phone *

Primary Language *

Interpreter Needed? *

• Yes
• No

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Referral Purpose

Referral Purpose (check all that apply) *

• DD Waiver Services
• Crisis Supports
• Residential Placement
• Behavioral Consultation
• In-Home or Community-Based Support
• Day Program / Employment
• Other (Please specify below)

If Other Please Indicate Below

Brief Summary of Need or Request *

Include present concerns and service history. Attach additional notes if needed.

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Diagnosis and Current Services

Primary Diagnosis (ICD-10) *

Secondary Diagnosis (if applicable)

Level of Support Needs *

• Low
• Moderate
• High
• Intensive

Current Services *

• Case Management
• Residential
• Day Program
• Employment
• In-Home
• Behavioral
• Other (Please specify below)

If selected Other

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Supporting Documentation Checklist

Please Attach the following (as applicable)

• Psychological Evaluation / Diagnosis Eligibility
• Person-Centered Plan (PCP)
• Individual Support Pan (ISP)
• Crisis Plan
• Functional Behavioral Assessment (if available)
• Medical Summary or Medication List
• VIDES
• VIC (Virginia Informed Choice)
• Educational or Vocational Reports
• Other (Please specify below)

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Preview & Submit

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