Service Request Form

Demographic Information

First Name

Last Name

Email

Phone Number

Street Address

Required if the referred individual is under 18 years of age.

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Phone Number

Which Program are you interested in?

Applied Behavioral Analysis

ADOS Testing

Substance Abuse Intensive Outpatient

Traditional Outpatient Therapy

Functional Family Therapy

Description of Presenting Issues

Insurance Provider

Policy ID

Please Select CoverageType

Medicaid

Medicare

Commercial

Federal (Tricare)

Self Pay

Group Number

Subscriber First Name

Subscriber Last Name

Subscriber Date of Birth

Relationship to Subscriber

Thanks for submitting!

Phone: 804.737.3917

Fax: 804.737.3940

©2023 by Civitas Health Services, Inc.
Licensed by the State of Virginia Department of Behavioral Health and Developmental Services.

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