Struggling with Opioid, Alcohol, or Drug Addiction? Call Now to Get Help: 757-938-3654

Patient Referral Form

Please download the Disclosure/Release Form and keep a copy for your records. If you plan to make an online submission please complete the required fields below.

If you prefer to make your referral by fax, phone, or email, please download the Patient Referral Form below.

Phone Number





Referral Overview

Patient Information

Referring Physician Information

Please be sure to fax, email, or attach any relevant patient medical records and history.

Fax: 757-938-3654

Review to ensure all information is accurate and then click Submit.

Virginia Beach: 1729 Wildwood Dr., Suite 103
Norfolk: 1711 Church Street, Suite B

Call Now 757-938-3654

DISCLAIMER: THIS WEBSITE DOES NOT PROVIDE MEDICAL ADVICE. The information contained on this website is not intended to be a substitute for or to be relied upon as medical advice, diagnosis, or treatment. This website is for informational purposes only. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

© 2022 Inspiration Health Addiction Treatment Clinic. All Rights Reserved.