ADMINISTRATIVE OFFICE: 1919 Commerce Drive, Suite 300, Hampton, VA 23666
OFFICE HOURS:Monday-Friday: 9 am to 5 pm
757-224-8017[email protected]

Outpatient Therapy Online Referral Form

Home Outpatient Therapy Online Referral Form

Please enable JavaScript in your browser to complete this form.

Date of Referral *

Gender *

Male
Female
Other

Identifies As

Name of Referral *

Age *

Date of Birth *

Phone Number *

Parent/Legal Guardian Name (if Referral is under 18 years old):

Relationship to Referral

Address *

Address Line 1

City

State

Zip Code

Region *

Is Referral currently receiving Intensive In-Home Services? *

If Yes, Name of IIH Agency?

Phone Number of IIH Agency:

Is Referral currently receiving Mental Health Skill-Building Services? *

If Yes, Name of MHSS Agency

Phone Number of MHSS Agency:

Preferred Therapist

Janiya Taylor, LPC, RPT, LPC-S
Ashinna Cole, LPC
Monique Simpson, LCSW

Type(s) of Counseling/Therapy Requested *

Individual Counseling
Family Counseling
Couples Counseling
Parenting Groups
Substance Abuse Group
Other

Does the Referral have Insurance? *

Select Insurance *

Aetna Better Health of Virginia
Anthem HealthKeepers Plus
BlueCross & BlueShield
Cigna
Magellan Complete Care of VA
Magellan Healthcare
Optum
Private Pay
Sentara Community Plans
Tricare
UnitedHealthcare
None
Other

Name of Insurance (if Other)

Insurance Policy Number *

Name of Primary Individual on Insurance *

Referred by (Name or Name & Agency/Department): *

Referral Source Email *

Desired Point of Contact (if referred by Agency/Department):

Phone Number of Referral Source or Desired Point of Contact (if referred by Agency/Department): *

FOR OFFICE USE ONLY

Date/Time of Initial Appointment

Time of Initial Appointment

Office Location

CONTACT US

Administrative Office

1919 Commerce Drive

Suite 300

Hampton, VA 23666

757-224-8017

757-224-8094

[email protected]

Main Office

700 Tech Center Parkway

Suite 200 – #40

Newport News, VA 23606

757-224-8017

757-224-8094

[email protected]

MESSAGE US

Please enable JavaScript in your browser to complete this form.

Name *

Email *

Message *