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Professional Referral
Please complete the following Referral Form and a office representative from Release and Renew Mental Wellness, LLC will contact you within 24-72 hours.
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* Indicates required question
Today's Date and Time
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MM
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DD
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YYYY
Time
:
AM
PM
Is the Patient under the age of 18?
*
Yes
No
Patient First Name:
*
Your answer
Patient Last Name:
*
Your answer
Patient DOB:
*
MM
/
DD
/
YYYY
Patient Address:
*
Your answer
Patient Apt no:
Your answer
Patient City:
*
Your answer
Patient State:
*
Your answer
Patient Zip Code:
*
Your answer
Patient Contact Information: (Phone)
*
Your answer
Patient Contact Information: (Email)
If you do not have one put N/A
*
Your answer
Patient Insurance Information
*
Maryland Medical Assistance
Optum Health
United Healthcare PPO
BCBS/OON
Aetna PPO/POS
Cigna PPO/POS
UHC Student Resources
Meritain
Oxford Health Plans
Nippon
Harvard Pilgrim
Self Pay
Uninsured
Other:
Required
Mental Health Diagnosis/History:
*
Your answer
Patient Guardian First Name:
Your answer
Patient Guardian Last Name:
Your answer
Patient Guardian Phone Number
Your answer
Patient Guardian Email Address:
Your answer
Referring Provider First Name:
Your answer
Referring Provider Last Name
Your answer
Referring Provider Contact Number
Your answer
Referring Provider Email Address:
Your answer
Referring Provider
LCSW-C
LCPC
PCP
PRP
Psychiatric NP
Psychiatrist
School Psychologist
School Counselor
Specialist
Other:
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