Programs and Admissions > Adult Programs > Referrals

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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	Male  Female
Race:	Please Select One White African American American Indian Asian Pacific Islander Other
Married:	Yes
Pregnant?	Yes

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?		Yes
If Yes, Case Manager	Name:
	Address:
	Phone:

Service Requested:	Please Select One Fredericksburg Lexington Lynchburg South Hill Waynesboro Zuni
Payment Source:	Please Select One Medicaid Waiver Supplemental Security Income Private Pay Social Security and Disability
Current Location:
	Diagnosis:
	Does the person has a diagnosis of mental retardation?	Yes
	Please list all mental health diagnosis:
	Please list all medical diagnosis:
	Does the person have any of the following medical needs:
	Ventilator Dependent?	Yes
	Dermal Ulcers III and IV that are unhealed?	Yes
	Intravenous therapy needed?	Yes
	Airborne infectious disease--communicable?	Yes
	Psychotropic medication without diagnosis. & treatment plan?	Yes
	Nasogastric tubes?	Yes
	Gastric tube?	Yes
	Require continuous licensed care?	Yes
	Other Medical Issues:
	Arson or fire setting	Yes
	Violent behaviors	Yes
	Threat to self or others	Yes
	Substance Abuse	Yes
	Self-injurious behaviors	Yes
	Sex offender adjudicated	Yes
	Sex offender/acting out	Yes
	Suicidal Behavior	Yes
	Medical issues w/ lack of compliance w/ treatment	Yes
	Comments:

 

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