VPGH Referral Form

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.

Date of Referral

Date

Person making referral:

How did you hear about us?

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.

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.

Date of Birth

Date

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):

Method of referral (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?