Serenity Treatment Center, Inc. Referral Form -   On Our Own of Frederick County
Referral form to Dr. L.A. McCrae & Serenity Treatment Center
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Email *
Who referred you?
Date of Referral
Full Name *
Date of Birth (MM/DD/YYY) *
Phone Number *
Preferred Method of Contact *
Preferred Method of Therapy *
Have you currently signed your Release of Information? If not, please do so at *
Street Address *
City *
State *
Zip Code *
Reason for referral, check all that apply: *
Do you have insurance? *
If you have insurance, please list the name of your insurance company.
If you have medical assistance, please provide MA# (i.e. Medicaid) or SSN.
Additional Information
Please feel free to list any other information that you would like our clinical team to review or know. This is a confidental space and a non-judgement zone.
Next Steps (for the person referring).
Sending a signed release of information form ( along with this referral form will allow our clinical staff to notify you whether or not your client appeared for their appointment. It is helpful to have all areas of this form completed so we can provide the best service to the individual that you have referred.
Instructions (for new clients)
Please call the office at (301)-898-2627 to schedule your assessment. This is the first step in the process. Everyone will complete an initial assessment so we can best determine a plan to address your needs and focal areas.

Please bring a form of ID and your insurance card to your first scheduled appointment. You may also email this information to
Serenity Treatment Center
420 East Patrick Street
Suite 100
Frederick, MD 21701

p (301)-898-2627
f (301)-898-2640
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