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:

SelfSpouse/PartnerOther family/friendHelpline CounselorClinicianPeer Recovery SpecialistOther
How did you hear about us?

HelplineClinicianCPRSOther providerFamily/friendWebsite/online/social mediaApp/EviveOther
Name of person making referral:

First NameLast Name
Do we have permission to contact you regarding this referral, if needed?

YesNo
Email of person making referral:
example@example.com
Phone number of person making referral:
Please enter a valid phone number.
Preferred method of contact of person making referral:

EmailPhone textPhone callOther
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?

YesNo
Do we have consent to identify as Virginia Partnership for Gaming and Health when we contact the person requesting services?

YesNo
Email of person requesting services:
example@example.com
Phone Number of person requesting services:
Please enter a valid phone number.
Preferred method of contact of person requesting services:

EmailPhone (text)Phone (call)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:

Woman/Cisgender WomanMan/Cisgender ManTransgender WomanTransgender ManNon-BinaryPrefer not to respondNot listedUnknown
If not listed and choose to reply:
What prompted reaching out for help?
Disposition of referral: (for office use only)

Intake completedDid not respond/unable to reachOtherDuplicate referralDeclined intakeCurrent in VPGH (referred by self or provider for additional services/resources)Not a Virginia resident, provided resources in home stateNot a Virginia resident, separate referral for in-state loved oneIn ProgressContact information incompleteRequested resources 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?

YesNo
Should be Empty: