Request Services

Western Tidewater


Please enter a referral for services using our secure form below. Please be sure that all required fields are entered and you press submit. Successful transmission of your referral will show you a thank you screen.

An intake team member will be in contact within 24 hours. If you need assistance before then, please contact our office at: 757.644.6391, and we would be happy to assist you.

NOTE: If you are looking to refer a client to one of our other community-based program within the Hampton Roads region, we kindly request that you follow these steps: Navigate to the ‘Request Services’ section and select ‘Hampton Roads’ from the available options.



    Referring Agency

    Reason for Referral