The Counseling Alliance of Virginia

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  - Referral Form
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Home
About
Services
Client Registration
- Richmond
  - Referral Form
- Charlottesville
  - Referral Form
Careers
- Come Join Our Team
Events
Contact
- Richmond Directions
- Cville Directions

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Notice of Privacy Practices

Client Name(Required)

First Middle Last

Social Security #(Required)

D.O.B.(Required)

Month

Day

Year

• I have been fully oriented to the services being provided as well as services which are available:

CAVA MISSION
CONFIDENTIALITY PRACTICES
GRIEVANCE PROCEDURES
BUILDING LAYOUT
HOURS OF OPERATION
CANCELLATION POLICY
HUMAN RIGHTS
FINANCIAL POLICIES
CAVA SERVICES
AFTER HOURS-CRISIS INTERVENTION SUPPORT
TREATMENT PARTICIPATION & DISCHARGE
FIRE SAFETY AND EMERGENCY PREPAREDNESS

• I have freely chosen to seek services with Counseling Alliance of VA, LLC (CAVA)
• I have read and agree to the information above.

Signature of Client

Signature of Parent/Guardian/Responsible Party*

NOTICE OF PRIVACY PRACTICES

Receipt and Acknowledgement of Notice

I hereby acknowledge that I have received and have been given an opportunity to read a copy of Counseling Alliance of VA, LLC’s Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Privacy Coordinator at 804-346-5165.

Signature of Client

Signature of Parent/Guardian/Responsible Party*

*If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.).

Client refuses to acknowledge receipt:

Signature of Staff Member

CAVA Referral Form

Select Location(Required)

Richmond

Charlottesville

Referral Date(Required)

MM slash DD slash YYYY

Admission Date - Office Use Only

MM slash DD slash YYYY

Client Information

Name(Required)

First Middle Last

Date of Birth(Required)

MM slash DD slash YYYY

Email(Required)

Age

Social Security #

Place of Employment or School

Marital Status(Required)

Sex

Gender Identity

Race

Indigenous or American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Undocumented

My Race is not listed

Prefer Not to Answer

Referral Source Information

Name(Required)

Agency or Person

Phone(Required)

Email(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Reason for Referral(Required)

Services Requested(Required)

Suggested Day

Suggested Time and Availability

Hours

Minutes

AM/PM

Suggestions for preferred provider

Platform

Parent/Guardian Information

(If under 18, parent’s/guardian’s information is needed. If you are 18 and over, please state SELF for name and fill out your contact information.)

Name(Required)

First Middle Last

Parents/Guardians are aware we will be contacting them.

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Can we leave a voice message?(Required)

Emergency Contact Information

Emergency Contact Information same as above?

Yes

Name(Required)

First Last

Relationship

Phone(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code

Insurance/Funding

Funding Source(Required)

Referring CSA County

List of counties

Medicaid Insurance Companies(Required)

Commercial Insurance Companies(Required)

Coverage Begins(Required)

Month

Day

Year

Coverage Ends(Required)

Month

Day

Year

ID(Required)

Client Relation to Subscriber(Required)

Please Upload Your Insurance Card - FRONT(Required)

Max. file size: 25 MB.

Please Upload Your Insurance Card - BACK(Required)

Max. file size: 25 MB.

Please Upload Relevant Documents

Max. file size: 25 MB.

Our Locations

Richmond
2924 Emerywood Parkway
Suite 200
Richmond, Virginia 23294

Phone: 804.346.5165
Fax: 804.346.5167

Charlottesville
335 Greenbriar Dr.
Suite 206
Charlottesville, Virginia 22901

Phone: 434.220.0333
Fax: 434.220.1647

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About CAVA

About CAVA
CAVA Executive Director
Richmond Staff
Charlottesville Staff
Contact Us
Request an Appointment

Our Services

Outpatient Services
Community Based Services
Mind Body Spirit

Client Registration

Richmond
Charlottesville

Related Resources

Local Human Rights
Virginia Department of Behavioral Health & Developmental Services
VA Board of Social Work
VA Board of Counseling
NASW
American Counseling Association
Virginia 211
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