Referral Form

Master Center Referral Form

Please note that this form is intended for clinical referrals only. If you would like to submit a self-referral or are requesting an appointment on behalf of a family member or friend, please click here.

Referred By

First Name

Last Name

Referral Contact Email

Referral Contact Phone

Patient Demographics

Patient First Name*

Patient Last Name*

Patient DOB*

Patient Phone*

Address*

Street Address City State ZIP Code

Reason for Referral Details*

Insurance Information

Insurance Company*

Subscriber First Name*

Subscriber Last Name*

Subscriber DOB*

Insurance ID*

Group #*

Insurance MH/SA Phone #*

2nd Insurance Company

2nd Insurance ID

2nd Group #

2nd Insurance MH/SA Phone #

Follow Up

Untitled

Please call the patient directly.

Please call the referring practice directly.

Get help today.

Our team of addiction medicine experts are compassionate and committed to making addiction treatment accessible, understandable, and affordable.

Use the confidential form below to request an outpatient or telehealth appointment, ask a question, seek help for a loved one, or request more information about addiction medicine. We're here to help! You may also call us at 804.552.5122.

First Name*

Last Name*

Date of Birth

Email*

Phone*

Master Center Referral Form

Referred By

Patient Demographics

Insurance Information

Follow Up

Get help today.

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Glen Allen

Gloucester

Hampton

Midlothian