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Your Full Name

Your Email Address

Telephone Number


I have reviewed the eligibility page?

I live on my own or in an assisted living facility (ALF).

I am at least 21 years old, or at least 18 years old and living on my own.

I have been diagnosed with a mental illness.

I am currently, or have been, hospitalized due to mental illness in the past.

I am medically insured through a Medicaid plan.

I have been prescribed medications for mental illness in the last 12 months.


I acknowledge that the information I have provided here is true to the best of my knowledge, and I authorized to provide this information to FELLC. I further agree that I would like FELLC to review this information in consideration of providing services to myself, or the individual to whom I am authorized to represent. I also agree and expect that the information I have provide remains confidential and will only used in the provision of services for the named individual. I have been advised that if I am experiencing an emergency, I should immediately leave this site and contact 911 for assistance.

Please sign your name here (type your name)


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Would you like to request service for yourself or on the behalf of someone else?


Let us know, confidentially, by completing the short form below.

Please check all that apply to your situation. 

Name (First only)

Email Address*

Telephone Number

Please include any additional information you would like to share.

I acknowledge that the information I have provided here is true to the best of my knowledge, and I am authorized to provide this information to FELLC. I further agree that I would like FELLC to review this information in consideration of providing services to myself, or an individual to whom I am authorized to represent. I also agree and expect that the information I have provided remains confidential and will only be used in the provision of services for the named individual. I have been advised that if I am experiencing an emergency, I should immediately leave this site and call 911 for assistance.   

How did you hear about us?

I am currently, or have been, hospitalized due to mental illness in the past.

I have reviewed the eligibility page?

I have been prescribed medications for mental illness in the last 12 months.

I am at least 21 years old, or at least 18 years old and living on my own.

I am medically insured through a Medicaid plan.

I have been diagnosed with a mental illness.

I live on my own or in an assisted living facility (ALF).

Number Format (111-111-1111)

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Please sign (type initials here)

* Please do not include an email addresses that identifies you..

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Amelia

Buckingham

Charles City

Charlotte

Chesterfield

Colonial Heights

Cumberland

Dinwiddie

Emporia

Goochland

Greensville

Hanover

Henrico

Hopewell

Lunenburg

New Kent

Nottoway

Petersburg

Powhatan

Prince Edward

Prince George

Richmond City

Surry

Sussex

 


We Serve the Counties of:

 

Contact Us!


Forever Endeavor, LLC

512 S. Bridge Street 

Farmville, VA 23901


Telephone: 434.315.0000

          Fax: 434.315.0001