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Team Hugging

Refer a Client to Our Services

At Gifted Ambition Health LLC and Trail of the Gifted Inc., we make it easy to connect individuals to the right level of care. Use this referral form to access our Partial Hospitalization Program (PHP) or Community Stabilization Services. Our intake team will review your referral within 24–48 hours. For urgent safety concerns, please call us directly.

Young Volunteers

Who We Help

 

This referral form is for individuals needing community assistance with non-clinical issues, including:

  • Housing resources and homelessness prevention.

  • Access to essential goods (food, clothing, hygiene products).

  • Veteran and Elderly advocacy.

  • Crisis and resource navigation support.

Referral Form

Referring Party Information

Date
Month
Day
Year

Client Information

Birthday
Month
Day
Year

Insurance Information

Service Requested
Safety Concerns (check all that apply)
Current Supports (check all that apply)
Reason for Referral (Check all that apply)
Primary Concerns

Authorization

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Date
Month
Day
Year
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
Month
Day
Year

Submission Instructions

• Submit this referral securely. Our intake team will follow up within 24–48 hours.

• For emergencies, call 911 or go to the nearest emergency department. Gifted Ambition Health, LLC | Licensed by Virginia DBHDS

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