Serenity Counseling Services of Virginia - New Client Referral Form
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.
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Email *
Client Full Name (Include preferred name in parentheses please) *
Date of Birth *
MM
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DD
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YYYY
Gender
*
Phone Number *
Address *
Email Address *
Which program are you seeking? *
Required
Insurance Provider *
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) *
When is placement needed?
*
History of or current substance use/abuse? (Please include last use for each substance and any previous substance abuse treatment) *
Please list all medications that the individual is currently taking: *
Are there any physical limitations that would cause challenges for the client to go up and down stairs? Please explain.
*
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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