Serenity Client Referral Form

To make a referral, please fill out the form below.

*www.SerenityMentalHealth.org*

We greatly appreciate your referral and guarantee the satisfaction of knowing your client is in the right hands. Here at Serenity Mental Health, we will speak with your client and/or the client’s family to discuss how our services will benefit them best. They will meet with one of our qualified mental health professionals to assess them and their needs. After the assessment we will then start the process to develop a treatment plan that will serve them the best and get approval for services through the insurance company. Upon approval, we will then meet to discuss which of our Serenity Providers will be the best fit for the client. They will be introduced and treatment will begin shortly after.

Referral Source (Radio, Printed Ad, Person, Drive-By, Doctor, Agency, etc…):

Please Check Service(s) Being Requested: ¨ Medication Management ¨ Therapy ¨ Assessment/Evaluation Only

¨ Substance Abuse Treatment ¨ Groups ¨ BST, PSR, or Day Treatment

Recipient’s Name: Date of Birth: Telephone#: Parent/ Guardian Name(s):

Insurance Carrier: Recipient ID#:

Presenting Problems or Significant Information:
Medications:

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

¨ I authorize Serenity Mental Health to release information to and obtain information from the following:

School/Organization/Medical Provider Phone Number Fax Number

Address City State/Zip

Patient Name: DOB:

Address: City: State/Zip:

Specific information to be released:

¨ Identifying Information ¨ Diagnostic Information

¨ Medical Information ¨ Complete Medical Records

¨ Therapy Notes ¨ Substance Information

¨ Billing Records ¨ Phone Consults Only

¨ Other

¨  I authorize release of these records through mail, facsimile transmission (FAX), or Email. I understand and agree that should the records be in advertently transmitted to an unauthorized recipient, through no fault of the sender, I hereby waive any claim against the sender and agree to hold the sender harmless from any and all responsibility for damages, if any, arising from the faulty transmission.

This authorization is in effect until termination of treatment or 12 months from the above date. I understand that I may change my mind at any time and revoke this authorization by notifying Serenity Mental Health and the above named entity in writing. I understand that changing my mind or refusing to sign this form will not affect my treatment. I understand that I have the right to inspect or copy any information disclosed under this authorization. I understand that once my health information is disclosed to the recipient, Serenity Mental Health cannot guarantee that the recipient will not disclose the health information to a third party or as required by law. I have read and understand this authorization and had a chance to ask questions about the disclosure of the health information. I authorize Serenity Mental Health and the above named entity to use my health information in the manner described above.

Patient or Parent/Guardian Signature: Date:

Email: info.serenitymentalhealth.org Fax: 702-815-1554

LAS VEGAS PAHRUMP BOULDER CITY CARSON CITY

*1901 S Jones-Las Vegas NV 89146 * 2280 East Calvada Ste,. #301-Pahrump, NV 89048 * 508 Nevada Way Ste. 3-Boulder City, NV 89005 * 755 N. Roop St.,Ste 101-Carson City, NV 89701 *

702-815-1550 775-751-5211 702-294-0119 775-841-6050