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ST. Angele Healthcare Services, Inc. · Virginia

Make a referral

For support coordinators, Community Services Boards and families. Fill in what you know and send the rest later — an incomplete form is better than a delayed one.

What we promise. We reply within two business days with a plain yes or no on capacity and a realistic start date. Our participation agreement lets us accept a referral only where services can genuinely begin within 30 calendar days, so we will tell you early rather than late.

Prefer paper? Download the referral form as a PDF and email it to marcelius@stangelhealth.com.

1. About you
2. The individual
3. Where they live

We need the address we would collect from and return to.

If they live in a group home, please also give us the house details. We will need to coordinate pick-up, drop-off and daily communication with the staff there.

4. Parent, guardian or authorized representative

Who we contact about this person. Leave blank if they make their own decisions and prefer we deal with them directly.

5. Service requested
6. Support needs

Tick anything that applies. Detail goes in the next section.

7. Doctors

Who we would contact in a health emergency, and who manages any psychiatric medication. Give what you have — we do not need records at this stage.

Primary care physician

Psychiatrist or behavioral health prescriber, if there is one

8. What a good week looks like

The most useful part of this form. What do they enjoy, what are they working toward, what should staff know on day one, and what does a bad day look like?

Download as PDF instead

We handle this information confidentially and in line with applicable privacy law. Please do not send a full Social Security number through this form.