When submitting your application, you can choose to fill out the electronic version below or fill out one of our physical copies. There is no need to fill out both.
If you need assistance with your application, please call us at 804-386-0925 or email us at [email protected].
Download and fill out your application. Click here to download it. When complete, upload it below.
Step 1 of 4
Has the individual needing services ever had any of the following?
1 - Needs Total Help | 2 - Needs significant help | 3 - Needs some help and supervision | 4 - Can complete but needs supervision | 5 - Fully independent, no help needed