Outpatient Therapy Online Referral FormPlease enable JavaScript in your browser to complete this form.Date of Referral *Gender *MaleFemaleReferral Name: *Age *Date of Birth *Phone Number *Parent/Legal Guardian Name (if Referral is under 18 years old):Relationship to Referral Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRegion *Please selectRegion 4 (Richmond)Region 4 (Prince Edward) Region 5 (Tidewater) Is Referral currently receiving Intensive In-Home Services? *NoYesIf Yes, Name of IIH Agency? Phone Number of IIH Agency: Is Referral currently receiving Mental Health Skill-Building Services? *NoYesIf Yes, Name of MHSS AgencyPhone Number of MHSS Agency: Preferred TherapistJaniya Johnson, LPC, RPTAshinna Cole, LPCMonique Simpson, LCSWType(s) of Counseling/Therapy Requested *Individual CounselingFamily CounselingCouples CounselingParenting GroupsSubstance Abuse GroupOtherDoes the Referral have Insurance? *NoYesSelect Insurance *Aetna Better Health of VirginiaAnthem HealthKeepers PlusBlueCross & BlueShieldCignaMagellan Complete Care of VAMagellan HealthcareOptima Health PlanOptumPrivate PayTricareUnitedHealthcareVirginia Premier Health PlanNoneOtherName of Insurance (if Other)Insurance Policy Number *Name of Primary Individual on Insurance *Referred by (Name or Name & Agency/Department): *Referral Source Email *Desired Point of Contact (if referred by Agency/Department):Phone Number of Referral Source or Desired Point of Contact (if referred by Agency/Department): *FOR OFFICE USE ONLY Date/Time of Initial Appointment Time of Initial Appointment Office LocationEmail Submit Application