Hampton Roads Counseling Services Peninsula

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FREE SERVICES FOR ELIGIBLE RECIPIENTS! SEE IF YOU QUALIFY

Eligibility Questionnaire



	The Emotional, the Violent, the Oppressed, Learning Victory through Empowerment!

To get started, we'll ask you a few simple questions about your child in order to determine if you may be eligible to receive services from our organization. ~ Click here to refresh the page or to start over

1. Is your child between the ages of 4 and 21?
Yes No


PENINSULA OFFICE: EMPORIA OFFICE: Employee LOGIN	2021 B Cunningham Drive Suite 2 Hampton Virginia 23666 320 South Main Street Second Floor Emporia, Virginia 23847 Ph: (757) 224-7986 \| Fax: (757) 325-8321 \| info@evolvellc.net \| Hours: 9:00 am - 5:00 pm Monday - Friday

2. Is your child enrolled in Medicaid?
Yes No

3. Has your child been referred to your local Community Service Board or a FAPT Team?
Yes No

4. Is at least one parent/legal guardian willing to participate in In-Home Services for the benefit of the child?
Yes No

5. Has your child demonstrated any behavior that is harmful to him/herself or others, i.e. drug/alcohol use, gang activity, physical threats/actions, sexually active?
Yes No

6. Has your child been involved in the criminal justice system in anyway i.e. has had to appear before a judge or had police contact?
Yes No

7. Has any disciplinary action been taken by a school against your child?
Yes No

8. Is your child at risk of being kicked out of a home due to negative behaviors?
Yes No

9. Has your child recently visited a counselor (either Guidance or Professional)?
Yes No

10. Does your child have an IEP or 504 plan?
Yes No

Unfortunately based on your answers you MAY NOT qualify for our services but that doesn’t mean we cannot help. Please visit here 'Additional Providers', for other organizations that may be able to be of service. For more information please contact your local Evolve office at (757) 224-7986.