Creative Approach Development Center Therapeutic Consultation Referral

Creative Approach Development Center

2819 N. Parham Rd. Suite 150, Richmond, VA 23294
Therapeutic Consultation Referral

To begin the intake process for a new client in need of behavioral supports, fill out the form below. Please keep in mind that completing this form does not guarantee behavioral supports will be provided for this person and this is the initial step in the screening process. Also, there is currently a waitlist with an expected start date for those accepted into the program of the of Late July 2023.
Prospective client initials*
Individual's Age*
Has this person worked with a Behavior Specialist in the past?*

YesNoI am not sure
Prospective client's diagnoses (please list each medical and mental health diagnosis.*
Case Manager/Support Coordinator/Person making the request*
Person making the request email address*
example@example.com
County the person lives in? *
Does this person have a DD Waiver?*

YesNo
If yes, is there a behavior plan?

YesNoI am not sure
Has this person ever been discharged from a behavior program/supports?*

YesNo
If they have been discharged from a behavior program/support, what was the reason?
What types of behavioral challenges is the person engaging in?(check all that apply)*

Emotional outbursts (crying, tantrums in response from not having desired outcome)Verbal aggression (yelling, screaming, cursing, threatening)Physical aggression (hitting, kicking, pushing)Property destruction (throwing objects, breaking them, crashing into them, writing on things)Consumption of non-food items (paper, frozen foods, dirt, string)Eloping (leaving areas without permission and letting someone know)Stealing (from stores, staff, peers, and/or family)Self-injurious behaviors (biting, scratching, skin/nail picking, banging head)Inappropriate sexual behaviors (exposing themselves, touching others, watching inappropriate videos in public areas, touching self in public areas)Isolation (lack of interacting with others, not leaving room, not wanting to go places)
Does this person engage in suicidal ideation?*

YesNoI don't know
If yes, has this person attempted suicide?

YesNoI don't know
Is this person at risk of losing placement?*

YesNoMaybe
Does this person require communication or any other accommodations to actively participate in services? (speech device, larger print materials, interpreter, etc.)*

YesNoI am not sure
If you selected, "yes" please explain.
You have completed the referral form. Please do not forget to click submit below (if filling out this form online). If you are filling out this form as a fillable PDF on your computer, save it when you are done and email it to Dr. Zipporah Levi-Shackleford at ZLShackleford@CreativeApproachOnline.com. Your form will be sent to Dr. Zipporah Levi-Shackleford who will review the information and email you about the status of the case. If more information is needed or if you have any questions, please email ZLShackleford@CreativeApproachOnline.com. Thank you for considering the Creative Approach Development Center.
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