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    Zuni

    Adult Referral

    Clients accepted into the Adult Services Programs must have a primary diagnosis of Mental Retardation and be 18 years of age or older. Clients must not be abusing any substance or engaging in any homicidal, suicidal or illegal activities. If you would like to speak to someone regarding the admission process, please call (434)-384-3131.

    First Name:
    Middle Initial:  
    Last Name:  
    DOB  
    Gender
    Race:  
    Married:
    Pregnant?
    Referral Source: Name:  
    Relation:  
    Address:  
    Phone:  
    Primary Family Contact Name:  
    Relation:  
    Address:  
    Phone:  
    Legal Guardian: Name:  
    Relation:  
    Address:  
    Phone:
    Does the person have a case manager at the CSB? 
    If Yes, Case Manager Name:  
    Address:  
    Phone:
    Service Requested:  
    Payment Source:  
    Current Location:  
    Diagnosis:
    Does the person has a diagnosis of mental retardation?
    Please list all mental health diagnosis:
     
    Please list all medical diagnosis:
     
    Does the person have any of the following medical needs:
    Ventilator Dependent?
    Dermal Ulcers III and IV that are unhealed?
    Intravenous therapy needed?
    Airborne infectious disease--communicable?
    Psychotropic medication without diagnosis. & treatment plan?
    Nasogastric tubes?
    Gastric tube?
    Require continuous licensed care?
    Other Medical Issues:
     
    Arson or fire setting
    Violent behaviors
    Threat to self or others
    Substance Abuse
    Self-injurious behaviors
    Sex offender adjudicated
    Sex offender/acting out
    Suicidal Behavior
    Medical issues w/ lack of compliance w/ treatment
    Comments:
     

     

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    • 150 Linden Avenue
    • Lynchburg, Virginia 24503
    • Phone: 434-384-3131