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Contact Information

First Name

Last Name

Phone *

Email *

Preferred Contact Method

Phone

Text

Client Information (if different from person filling out form)

Client Name

Relationship to Client

Self
Parent / Guardian
Case Manager
Provider
Other
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Reason for Referral / Support Needed

What brings you here today?

Type of Support Needed

Community Stabilization

Outpatient Therapy

Crisis Support

General Inquiry

Current Situation / Safety

Is the individual currently in crisis?

Yes

Unsure

Are there immediate safety concerns?

Yes

Insurance Information

Do you plan to use insurance for services?

No ( Self Pay )

Yes (please provide provider name and member ID below)

Insurance Provider

Member ID Number

Referral Source (optional but useful)

How did you hear about ECCS?

Hospital
Case Manager
School
Mobile Crisis Team
Internet
Word of Mouth
Other
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Additional Information

Notes / Anything else you’d like us to know

By checking this box, I consent to being contacted by ECCS for follow-up and support, I consent to receive transactional messages related to my account or services I have requested. These messages may include appointment reminders or confirmations, among other notifications . Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive messages, including follow up care notifications. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

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At ECCS, we believe that everyone has the power to create the life they desire.

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Region 5 Virginia

Request An Appointment

We're here to answer any questions you may have. Contact us today!

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