Referral for Therapy (Child)

PLEASE NOTE:

This is a form for agencies to refer clients. If you are the parent/guardian or self-referring, please complete the intake forms. Please call the numbers below with any questions

757-838-1960 (Newport News)
757-229-7940 (Williamsburg)

*If the referring agency requests an update on status of services, a release of information form must be provided.

*We do not currently have services provided in Spanish available.

Client Information

First name

Last name

Date of birth

Gender

Custody Status of Child

Both Parents Share Custody One Parent Has Custody Guardian(s) (Other) Has Custody Child Is in Foster Care Other Don't Know

Parent/Guardian Contact Information

Parent/Guardian Name (1)

Phone number

Email address

Street Address

City

Zip Code

State

Parent/Guardian Name (2)

Phone number

Email address

Street Address

City

Zip Code

State

Can we contact them by phone, email, and voicemail?

Yes No

If no, what is the preferred method of communication?

Referral Information

Referring Agency Name:

Referring Individual's Name

Referring Individual's Relationship to Client:

Referring Individual's Phone Number and/or Email Address

Referring for a Specific Counseling/Therapy Program?

Yes

If yes, which one? Please see our program descriptions under the "Services" tab

Project Peace

Thrive

Operation Home

VIPY

PATTS

Is the referring agency paying for services? If applicable

Yes No

Does the client have insurance?

Yes No Don't Know

Referring for:

Individual

Family

Are telehealth services needed? (typically only offered for children over 12 years old)

Yes No Don't Know

Medical History

Have they previously received therapy?

Yes No Don't Know

If yes, what is the therapist's name or location?

Have they previously been prescribed psychiatric medication?

Yes No Don't Know

If yes, what medications are they currently taking?

Reasons for Visit

Describe the reason for the referral.

Describe any goals or outcomes they may hope to achieve from therapy.

Describe any significant life changes or stressful events that they have recently experienced.

Is there anything else you'd like to tell us about?

Your information will be encrypted.

Our mission is to provide compassionate counseling and support services to foster resilience, promote healing, and empower individuals and families to lead stronger, more fulfilling lives. We are dedicated to helping people navigate life’s challenges by offering compassionate, evidence-based programs that foster informed decision-making, emotional health, financial stability, and strong family foundations. Our goal is to build healthier, more connected communities—one individual, one family at a time.