Serenity Counseling Services of Virginia - New Client Referral Form

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Please complete this referral and a representative of our team will reach out within 2 business days (does not include weekends or holidays). For immediate assistance or questions, please contact our office at 804-569-2100.

Email *

Client Full Name (Include preferred name in parentheses please) *

Date of Birth *

YYYY

Phone Number *

Address *

Email Address *

Which program are you seeking? *

Intensive In Home Services (Chidlren ages 5-21)

Mental Health Skill Building Services (Adults ages 18 and up)

Residential Crisis Stabilization (Adults ages 18 and up)

Required

Insurance Provider *

Aetna Better Health of Virginia - Medicaid

Anthem Healthkeepers Plus - Medicaid

Molina Complete Care - Medicaid

Optima - Medicaid

United Healthcare - Medicaid (we are not currently in network with this MCO)

Virginia Premier - Medicaid (we are not currently in network with this MCO)

Self Pay

Other:

Insurance / 12 Digit Medicaid ID *

If under 18, parent/guardian name: (First and Last)

Current Diagnosis, if any: *

Reason for Referral: (please include information about recent symptoms/behaviors that may be of concern) *

Please list all medications that the individual is currently taking: *

Previous Mental Health Hospitalizations? (please include month/year and reason for hospitalization) *

Please list any other providers or professionals that would be helpful to coordinate with throughout services: *

Referred By: (please include your name and phone number) *

How did you hear about Serenity Counseling Services of Virginia? *

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