* 1. Date of Request

Today's date

* 2. Date of Informed Consent to Participate

Date signed by individual/authorized representative
Informed Consent for Participation forms must be signed by the individual/authorized representative and SC/CM or SW prior to completion of this survey. Consent forms must be placed in the individual's case record.

Please complete this survey for each individual seeking community services. The information will be posted to DBHDS Developmental Services web site on the survey entitled List of Individuals Seeking Community Services Providers. Community providers who have completed the Provider Profile on Survey Monkey can respond and be considered by individuals seeking community services.

Individuals' unique identifiers will remain on the DBHDS website until you notify Tonya Carr (tonya.carr@dbhds.virginia.gov) or Benita Holland (benita.holland@dbhds.virginia.gov) that the individual has selected a provider. Please include the individual's unique identifier, CSB name and contact person in your email.