Referral Form

For providers referring a patient for mental-health services.

Securely submit a referral. We’ll contact the patient within 1–2 business days.

Leave this field empty

Referring Provider

Referring Provider Name * Practice / Clinic Name * Provider Email * Provider Phone * Provider Fax I would like follow-up regarding this referral

Patient Information

Patient Full Name * Date of Birth * Patient Phone * Patient Email * Preferred Contact Method * Insurance Carrier * Member ID Provider confirms patient consent to be contacted *

Clinical Information

Type of Service Requested * Presenting Concerns / DX * Current Medications

Risk / Safety Concerns? No Yes

Best Contact Time

By submitting, you confirm you have obtained patient consent. For urgent safety concerns, call 988 or emergency services.

Referral Form

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