Mental Health Treatment Request

The Mental Health Treatment Request is used by counselors or psychiatrists to verify the care they are providing is related to the crime incident. Once completed, this form will allow for payment of the first ten sessions of a trauma-informed treatment plan.

Form Instructions: 

The mental health provider should complete the Mental Health Treatment Request in its entirety.

Fax or mail to:
Virginia Victims Fund
P.O. Box 26927
Richmond, VA 23261
Fax: 804-823-6905