Referrals

You can refer a child by filling our Pre-placement Information Packet and fax or mail it to us. Download Pre-placement Information Packet and print it.

Download Admissions Packet  - revised 02/06/2015 (right click, save target as)

In this packet you will find an Authorization to Release Information form.
We need one separate form for medical, dental, school, psychiatry, therapy and court. One copy of this form exists in the Pre-placement Information Packet. You can download this form separately and print as many copies as you need.

Download authorization_release_form.pdf  (right click, save target as)

You need Adobe acrobat reader to view and print these forms.
If you don't have Adobe acrobat reader, you can download it there



For any complementary information about referring a client to us, contact Diane Pellek.

Phone: 804-684-2555
Cell: 804-832-0890
Fax: 804-642-6722

Mail to:
The Family Center of Hope
P.O. Box 752
Hayes, VA. 23072