Patient referral form.pdf
Fax your referral to (800) 694-3053.
Refer a patient to
We’ll contact the family within 24 hours, and their intake
will be within the next 3-6 days.
Once their intake is complete, we’ll let you know!
Family information
| Services of interest for patient (Select all that apply) | Child and family therapy | Parent counseling |
|---|---|---|
| Child name | Parent or guardian name | |
| Child date of birth | Parent or guardian phone number | |
| State of child's residence | Parent or guardian email address |
Referring physician
| Name of provider, clinic, or agency | Name of contact person |
|---|---|
| Referring pediatrician | Email of contact person |
| Office phone number | Office fax number |
| Referral notes | Optional: Add insurance, care or provider preferences, |