Make a referral

For service coordinators, families, guardians and community partners. We respond within one business day.

This website is not for emergencies. If someone is in immediate danger or needs urgent medical help, call 911.

About you

Your name

Your email address

Your phone number(optional)

Organization(optional)

If you are referring on behalf of one.

Your role(optional)

Your relationship to the person

For example: service coordinator, parent, guardian.

About the person being referred

Please share only the minimum needed for us to make contact. Do not include medical records, diagnoses, Social Security numbers or Medicaid numbers on this form.

Their first name(optional)

Last initial(optional)

Just the first letter of their surname.

City or ZIP code

General service interest(optional)

For example: respite, day habilitation.

Current program status(optional)

How soon is support needed?(optional)

This website is not for emergencies.

Getting in touch

Preferred contact method(optional)

Best time to reach you(optional)

Anything else we should know?(optional)

Please do not include medical records or other highly sensitive information.

I confirm I have the person’s consent, or the legal authority, to share this information with Serenity Homes Wellness.

We use these details only to respond to your referral. Read our Privacy Policy.