For Referring Providers (Physicians, Therapists, School Counselors)

If you are interested in receiving more information about our treatment services, or to refer a patient for treatment, please complete the form below and one of our psychologists will follow-up with you within 1 business day.  Please note this is not a secure form. 

You may also fax a referral form to us at 1-888-965-0579.

Referring Provider's Phone Number *
Referring Provider's Phone Number
With your patient's permission, you may include his/her contact information below. Please note that this is not a secure form.
Patient's Phone Number
Patient's Phone Number