The Barry Robinson Center
443 Kempsville Road
Norfolk, VA 23502
757-455-6100  1-800-221-1995 757-455-8508

REFERRAL INFORMATION

Disclaimer
Use of this referral form is the first step in the process for The Barry Robinson Center to consider your child for treatment services. Submission of this form will be followed up with a phone call. May we contact you by phone? 

Child's Name:    DOB:   Gender: 
Referral Source Name and Address: 
Referral Source Phone Number: 
Legal Guardian Name and Address (if different from Referral Source): 
Legal Guardian Phone Number: 
Reason for Referral: 
Type of Treatment Requested: 
Is the Child Currently in Treatment:  
   If yes, Name of Provider: 
   
Current Placement (include date entered and expected discharge, if applicable): 
 Name and Dates: 
 Name and Dates: 
 
Current Psychiatric Diagnosis: 
Axis I: 
Axis II: 
Axis III: 
Axis IV: 
Axis V: 
Current Medications: 
Education Information: 
School Attending:  Current Grade: 
IEP:  Spec. Ed. Classification: 
Involvement with the Legal System:   If yes, describe the reason:
Type of Insurance: 
  Have you been to FAPT?: 

ADDITIONAL REQUIRED INFORMATION TO BE MAILED OR FAXED (listed above)

    1. Psychiatric or Psychological Evaluation(s)
    2. Treatment records including outpatient provider records, inpatient records, etc.
    3. Social History
    4. Medical History
    5. School Information
    6. Other information may be requested as needed.
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Accredited By:
The Joint Commission
Virginia Association of Independent Specialized Education Facilities
Licensed By:
Virginia Department of Behavioral Health and Developmental Services
Virginia Department of Education
Virginia Department of Social Services
Copyright © 2006 Barry Robinson Center. All Rights Reserved. Privacy Notice
The Barry Robinson Center agrees that no child shall be discriminated against because of race, religion, color, sex, age, handicap or national origin. Any individual who has concerns about client care and safety at BRC, that have not been addressed by BRC, is encouraged to call the BRC Compliance Office. If concerns remain unresolved after contacting BRC Compliance Office, individuals may contact The Joint Commission.
The Barry Robinson Center is a Drug Free Environment.
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discrimination on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write: USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
The Barry Robinson Center is an equal opportunity employer. The Barry Robinson Center does not discriminate in employment on the basis of race, color, religious creed, national origin, sex or ancestry or on the basis of age or physical or mental handicap unrelated to ability to perform the work required.