VPGH Referral Form

VPGH Referral Form

Thank you for reaching out to VPGH. One of our Certified Peer Recovery Specialists will reach out within 24-48 hours to assist you with next steps of your journey. This form is HIPAA compliant and any information you provide is protected.
If this is an emergency please call 911 or visit your local emergency room. If you need emotional support or are having thoughts of self-harm, please reach out for immediate help by calling the 988 Suicide and Crisis Lifeline. This confidential service is available 24/7.
Person making referral:

Other
How did you hear about us?

Other
Name of person making referral:

First NameLast Name
Do we have permission to contact you regarding this referral, if needed?
Email of person making referral:
example@example.com
Phone number of person making referral:
Please enter a valid phone number.Format: (000) 000-0000.
Preferred method of contact of person making referral:

Other
If other, please specify:
Preferred time of contact for person making referral (between 8a-6p, Monday-Friday). Please note that someone will reach out within 24-48 hours.
Please upload helpline intake, if applicable.

Cancelof
Name of person requesting services:

First NameLast Name
Do we have permission to contact the person requesting services?
Do we have consent to identify as Virginia Partnership for Gaming and Health when we contact the person requesting services?
Email of person requesting services:
example@example.com
Phone Number of person requesting services:
Please enter a valid phone number.Format: (000) 000-0000.
Preferred method of contact of person requesting services:

Other
If other, please specify:
Preferred time of contact for person requesting services(between 8a-6p, Monday-Friday). Please note that someone will reach out within 24-48 hours.
Age:
Gender:
If not listed and choose to reply:
What prompted reaching out for help?
Disposition of referral: (for office use only)
If other, please specify: (if this is a duplicate, please be sure to enter the support seekers existing ID for reference)
Support Seeker ID (for office use only)
VPGH CPRS handling referral: (For office use only)
If this changes before the intake is completed, please list the alternative CPRS name. ONLY enter first and last names in this space.
CPRS Notes (For office use only):
Time spent on referral (does not include time reported if an intake was/will be completed):
Are you seeking resources for yourself?
Should be Empty: