Referrals

Fill out referral form below. The form will be sent to our Centralized Scheduling Department and the client will be added to our system

"*" indicates required fields

Step 1 of 2

Referring Provider Name*
SMS Opt-in

Patient Demographic Information

Patient's Name*
Patient's County*
Please select the county in which the referred patient resides. If they do not live in one of the 3 counties listed, they are outside of SBH's catchment area and we cannot accept the referral. If this is the case, please abandon this form and visit: https://vacsb.org/csb-bha-directory/ to find their local Community Services Board