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Empowering Individuals To Empower Themselves

804-353-3585

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Referrals

Thanks for contacting Brothers' Keeper Inc. We received your message and will respond a quickly as possible.

Have Mental Health Services been received before? If yes, please describe:

Select type of service for eligibility requirements

Eligibility and Documentation:

(At least two of the following criteria must be met to qualify for services):

Has difficulty due to mental, behavioral, or emotional illness in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out of home placement because of conflicts with family or community;

Exhibits such inappropriate behavior due to mental, behavioral, or emotional illness that repeated interventions by mental health, social services, or judicial system are necessary and or;

Exhibits difficulty in cognitive ability due to mental, behavioral, or emotional illness such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior. For example, is at risk of acting out in such a fashion that will cause harm to themselves or others;

Currently taking or has an extensive history with taking Psychotropic medication due to mental illness.


NOTE: Check here if an independent clinical assessment has been completed? (A clinical assessment must be completed before services can begin.)

 Please select at least two applicable options to submit

Eligibility and Documentation:

(At least two of the following criteria must be met to qualify for services):

Has behavioral challenges in the home environment, to include but not limited to physical aggression towards parent/guardian, siblings, relatives, etc., aggressive and/or threatening language, destruction of property, temper tantrums, problems in the community, inability to comply with authority figures directive, internal emotional struggles, suicidal/homicidal ideations, depressive symptoms. (Within the last 30 days.)

Has behavioral challenges in the school setting, to include but not limited to repeated OSS, ISS, silent lunches, class removal, sent to the office, sent to another class room, bus suspensions, difficulty getting along with peers, insubordinate to authority, destruction of property, physical and/or verbal aggression towards staff or peers.(Within the last 30 days.)

We have obtained a copy of the clients' disciplinary record for the last six month period. (this may involve clients' previous school if they recently changed schools, attendance record, and most recent report card.)

 Please select at least two applicable options to submit

Eligibility and Documentation:

(At least two of the following criteria must be met to qualify for services):

Experiences difficulty in establishing or maintaining normal interpersonal relationships to such a degree that the individual is at risk of psychiatric hospitalization, homelessness, or isolation from social supports;

Experiences difficulty in activities of daily living such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree the health or safety is jeopardized;

Exhibits such inappropriate behavior that immediate interventions by mental heath, social services, or judicial system are necessary; or

Exhibits difficulty in cognitive ability such that they are unable to recognize personal danger or significantly inappropriate social behavior.

 Please select at least two applicable options to submit

Eligibility and Documentation:

(At least two of the following criteria must be met to qualify for services):

Has difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with family or community.

Exhibits such inappropriate behavior thats documented, repeated interventions by the mental health, social services, or judicial system are or have been necessary resulting in being at risk for out of home placement.

Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior resulting in being at risk for out of home placement.


NOTE: Check here if an independent clinical assessment has been completed? (A clinical assessment must be completed before services can begin.)

 Please select at least two applicable options to submit

Eligibility and Documentation:

(At least two of the following criteria must be met to qualify for services):

Has difficulty due to mental, behavioral, or emotional illness in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out of home placement because of conflicts with family or community;

Exhibits such inappropriate behavior due to mental, behavioral, or emotional illness that repeated interventions by mental health, social services, or judicial system are necessary and or;

Exhibits difficulty in cognitive ability due to mental, behavioral, or emotional illness such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior. For example, is at risk of acting out in such a fashion that will cause harm to themselves or others;

Currently taking or has an extensive history with taking Psychotropic medication due to mental illness.


NOTE: Check here if an independent clinical assessment has been completed? (A clinical assessment must be completed before services can begin.)

 Please select at least two applicable options to submit

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