Release Wellness Provider Referral Form
Release Wellness partners with medical providers, hospitals, and community organizations to ensure timely access to outpatient behavioral health services. We accept provider referrals for routine and urgent mental health needs, including same-day Open-Access Walk-In evaluations when clinically appropriate. Referrals submitted through this page are reviewed promptly by our clinical team.
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How to Refer a Patient
Providers may refer patients to Release Wellness using the secure referral form below. Once a referral is received, our team will review the information and contact the patient directly to coordinate care or guide them to appropriate walk-in access. For urgent coordination or same-day walk-in recommendations, providers may also contact our office by phone. Referral Phone: 757-751-9508 | Fax: 757-210-4405 Email: referrals@releaseyourwellness.com
Referring Provider Information
Practice or Organization Name
*
Referring Provider Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Email
*
example@example.com
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Patient Information
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Reason for Referral
*
Brief description of presenting concerns
*
Relevant clinical history
*
Current level of risk if applicable
*
Date of Referral
*
-
Month
-
Day
Year
Date
Urgency
*
Not Urgent
1
2
3
4
Extremely Urgent
5
1 is Not Urgent, 5 is Extremely Urgent
Referral Type
*
Routine outpatient referral
Urgent referral
Same-day Open-Access Walk
Additional Information
*
Please Select
Recent hospitalization
Recent incarceration or system transition
Medication concerns
Safety concerns
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Submit Referral
Open-Access Walk-In Mental Health Appointments
Release Wellness offers Open-Access Walk-In Mental Health Appointments for patients who require timely clinical assessment and stabilization but do not meet criteria for emergency hospitalization. Patients referred for walk-in care may present directly during designated walk-in hours. No appointment is required. Walk-in visits include a same-day clinical assessment, risk evaluation, safety planning, and coordination of follow-up care. For questions regarding appropriateness of walk-in referrals, providers are encouraged to contact our clinical team.
Insurance Accepted
Release Wellness accepts Medicaid and most major commercial insurance plans. Insurance eligibility is verified prior to services whenever possible. Patients without active coverage may contact our office to discuss options. For insurance-specific questions, providers may contact our administrative team directly.
Consent Confirmation
*
I confirm that the patient is aware of and consents to this referral
This referral page is intended for outpatient behavioral health services. Patients experiencing medical emergencies or requiring immediate inpatient psychiatric care should be directed to emergency services. Release Wellness | Newport News, Virginia | Phone: 757-751-9508 | Fax: 757-210-4405 Email: referrals@releaseyourwellness.com | Website: www.releaseyourwellness.com
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