Secure Referral Submission

Submit a Referral

Complete this form to refer an individual for residential services. Our team responds within 24–48 business hours.

All information is encrypted and handled with strict confidentiality

Client Demographics

Personal information about the individual being referred

First Name *

Last Name *

Date of Birth *

Social Security Number(encrypted)

Gender

Client Phone

Client Email

Current Address

Diagnosis & Level of Care

Clinical information to assess appropriate placement

Primary Diagnosis *

Secondary / Co-occurring Diagnosis

Level of Care

Current Living Situation *

Waivers Enrolled

Mobility Needs

Behavioral Support Needs

Medication Needs

Heavy Medical / High-Acuity Needs— Soul Spring specializes in medically complex individuals

Medical Complexity Level

Medical Complexity Details

We accept high-acuity CL Waiver individuals. The more detail you provide, the faster we can assess fit.

CSB & Case Manager Information

Contact details for follow-up and coordination

Community Services Board (CSB) Name *

Case Manager / Support Coordinator Name *

Case Manager Phone *

Case Manager Email *

Case Manager Fax

Guardian / Substitute Decision Maker

(if applicable)

Complete if the individual has a legal guardian, conservator, or power of attorney.

Guardian Name

Relationship

Guardian Phone

Guardian Email

Referral Preferences & Urgency

Help us prioritize and match this referral appropriately

Urgency Level *

Bed Availability Preference *

Preferred Locality in Southwestern VA

Additional Notes or Special Considerations

By submitting this referral, you confirm that you are an authorized referral facilitator (CSB Support Coordinator or contracted case manager) and that you have obtained appropriate consent from the individual or their legal decision maker to share this information with Soul Spring Residential Services.

Your submission is encrypted and secure. We respond within 24–48 business hours.