• Contact Us:

Licensed by the Virginia Department of Behavioral Health and Developmental Services

  • Follow Us:
Make An Appointment

Contact Us

Ready to reach out to us? Fill out the form below or contact us directly at 804-471-3699. We are eager to hear from you and provide you with the information and assistance you require.

Remember, at Rochelle Home, we are committed to excellent communication and ensuring that your inquiries are addressed in a timely manner. Don’t hesitate to contact us—take the next step and connect with us today.

DOWNLOAD FORM

Website Inquiry Form

Rochelle Home, LLC



Inquiry Form for Potential Residents

Thank you for considering our Mental Health Group Home as a potential living option. We strive to provide a safe and supportive environment for individuals seeking mental health assistance. Please take a few moments to complete this inquiry form so that we can better und

Personal Information

Full Name
MM slash DD slash YYYY
Address

Mental Health Information

1. Do you have a diagnosed mental health condition? If yes, please specify
3. Are you currently receiving mental health therapy or counseling? If yes, please provide details
4. Have you been hospitalized for mental health reasons in the past six months? If yes, please elaborate
5. Are you currently taking any medications for your mental health condition? If yes, please list them
Untitled
6. Do you have a history of substance abuse? If yes, please provide details
7. Have you ever lived in a group home or residential treatment facility before? If yes, please specify
Untitled
8. Are you involved in any legal matters related to your mental health condition? If yes, please explain
Untitled

Living Arrangement

Additional Information



Consent:

By submitting this inquiry form, you acknowledge that the information provided is accurate to the best of your knowledge. You also authorize our staff to use this information for the purpose of evaluating your suitability for our Mental Health Group Home and to contact you using the provided contact details.
Once we receive your inquiry form, our team will review it and reach out to you to discuss the next steps. If you have any urgent concerns or need immediate assistance, please contact us directly at 804-471-3699.

Thank you for considering our Rochelle Home as a potential place to support your mental health journey. We are here to help and look forward to assisting you in any way we can.

Quick Links

Our Services

Contact us

Call Us

804-471-3699

Email Us

info@rochellehome.org

Address

102 Crescent Ave Hopewell, VA 23860

Copyright © 2024 · Rochelle Home · Website Design by SpringHive