SERENUS HEALTHCARE

Refer a Patient

Psychiatry Referral Form for Providers

Referral Form

Complete our referral form, and we’ll gladly reach out to your patient, or give them our website, and they can complete our online self-triage process.

Patient's first name *

Patient's last name *

Patient's location *

Patient's email address *

Patient's mobile phone

Patient's mobile phone *

Patient's date of birth (MM/DD/YYYY) *

Month

Day

Year

Patient's insurance

Only in-network plans are shown. If your patient's insurance isn’t listed, we’re out-of-network, and payment is out-of-pocket. We can help with out-of-network reimbursement submissions.

Member ID

If you'd like your patient to see a specific psych NP at Lavender, please provide the psych NP's name

Reason for referral *

Psychotherapy

Medication management

Psychotherapy and medication management

Other

Please elaborate on patient care needs, if appropriate

Referring practice/provider name

Referring practice/provider email

Referring practice/provider phone

How did you hear about us?

If Other, please describe