Programs and Admissions > Adult Programs > Referrals

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Adult Referral

Individuals in the Adult Services Programs must have a primary diagnosis of an intellectual disability and must be 18 or older. The individuals 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, ext. 3622 or ext. 3643.

Or you can fill out the information below and someone in our Adult Services Office will contact you about the admissions process.

First Name:
Middle Initial:
Last Name:
DOB
Gender	Male  Female
Does this individual have a diagnosis of an intellectual disability?	Yes
Married:	Yes
Pregnant?	Yes

Referral Source:	Name:
	Relation:
	Address:
	Phone:
	Email:
Primary Family Contact	Name:
	Relation:
	Address:
	Phone:
	Email:
Legal Guardian/ Authorized Representative:	Name:
	Relation:
	Address:
	Phone:
	Email:
Does the person have a Case Manager/Support Coordinator at the CSB?		Yes
If Yes, Case Manager/ Support Coordinator	Name:
	Address:
	Phone:
	Email:

What program is the invidual interested in?	Group Home Supervised Living Apartment Sponsored Homes
Where does the individual want to live? (check all that apply)	Frederiscksburg  Lexington  Lynchburg  South Hill Stuarts Draft  Waynesboro  Zuni  Any
Payment Source: (check all that apply)	Medicaid Waiver  Supplemental Security Income  Social Security and Disability  Private Pay
Where does the individual live currently?
Comments/ Questions

 

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