Outpatient Referrals

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Frederick & Hagerstown Treatment Center Locations

Online Outpatient Referral Form

Thank you for your interest in our outpatient treatment programs. Please read all of these instructions completely before filling out our convenient online form.

Instructions for clients:

Please call our office if you need to make an appointment (see contact info below). When you arrive for your first appointment, please provide a form of ID and your insurance card.

If you'd prefer to download and print the form:

Hagerstown Referral Form PDF: click here

Frederick Referral Form PDF: click here

If you have questions about this application or prefer to submit via email or fax, please click below to get contact information for both locations.

Referral Form

Please fill out the form below, completing all sections. If a question does not apply, please type N/A. Once you submit the form, you’ll receive a confirmation email to the email address you provide.

Serenity Location

Referred By:

Phone Number:

Email:

Preferred Method of Contact

Do you currently have a Release of Information signed?

Yes No

Client First Name

Client Last Name

Date Of Referral

Client Address

City

State

Zip Code

Date Of Birth

Reason for referral, check all that apply:

Assessment with treatment recommendations Other

If you selected "other," explain here:

Will the client call and schedule him/herself for an appointment?

Does the client have insurance?

If yes, name of insurance company:

If client has medical assistance, please provide MA # or SSN:

Additional comments:

Enter your preferred email to receive form submission confirmation: