Referral/ Service Request

Please use the secure form below to send us a referral for services. Fill in all required fields and click Submit. Once your referral goes through, you’ll see a “Thank You” confirmation screen.

A member of our intake team will contact you within 24 hours.
If you need help sooner, call us at 757-319-3152 and we’ll be glad to assist you.

Client Name

DOB

Client Phone Number

Client Email

Client Gender

Street Address

City

State

Zipcode

Parent/Guardian

Name

Relationship to Client

Phone Number

Insurance

MCO

Medicaid Number

Member ID

Social Security Number

Referring Agency

Referral Agency Name

Name of Person Making the Referral

Referral Email

Referral Phone Number

Requested Service

Community Stabilization

Crisis Counseling

Reason for Referral

Check all that apply

Suicidal thoughts and/or attempt

Current psychiatric hospitalization or ER visit

Discharge from hospital, rehab, jail, or group home

Increase in severe mental health symptoms

Major life change or stressful event

I acknowledge that by submitting this referral, a Wellview staff member will review the information and may contact the referral source and/or the client to confirm details and discuss next steps.

General Service Questions?