For Healthcare Professionals

Provider Referrals

Referring a Patient to Serene Psychiatry

We welcome referrals from physicians, therapists, school counselors, and other healthcare professionals. Submit referrals online or by fax. Our office reviews each referral and coordinates next steps with the patient or guardian.

In-Person · Clinton, MSTelehealth Throughout Mississippi

Submit a Patient Referral

Complete the form below. Upon submission, a formatted referral document will be sent to our care team for prompt follow-up. All fields marked with an asterisk are required.

Referring Provider Information

Referring Provider's Full Name*

Practice or Facility Name*

Professional Title / Credentials(optional)

Phone Number*

Fax Number(optional)

Professional Email Address(optional)

Patient Information

Patient's Full Legal Name*

Date of Birth*

Patient or Guardian Phone Number*

Parent / Legal Guardian Name(optional)

Social Security numbers are not collected.

Referral Details

Requested Service*

Appointment Preference*

Referral Priority*

Reason for Referral*

Additional Clinical Information (Optional)

Relevant Symptoms or Diagnoses(optional)

Current Psychiatric Medications(optional)

Prior Treatment or Hospitalizations(optional)

Pertinent Medical History(optional)

Additional Notes for the Receiving Provider(optional)

Please include only records directly relevant to this referral. Do not attach documents containing Social Security numbers or unrelated protected health information.

Confirmation

I confirm that I am submitting this referral in my professional capacity and that the information provided is accurate to the best of my knowledge. Any necessary patient permissions and applicable confidentiality requirements have been addressed.

Submission does not guarantee acceptance or appointment scheduling. Please allow 1–2 business days for routine referral review.

For psychiatric emergencies, please direct patients to call 988 (Suicide & Crisis Lifeline), go to the nearest emergency room, or call 911. This form is not monitored in real time and is not appropriate for crisis situations.