For Referring Providers
(Physicians, Therapists, School Counselors)

If you are interested in receiving more information about our services, or to refer a patient for treatment, please complete the form below.  Please note this is not a secure form. You may also fax a referral form to 1-888-965-0579.  In addition, you can download a copy of our brochure for your patients or request hard copies of our brochure be sent to your office.

 
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
 

 

Digital Brochure

You can download a copy of our brochure for your patients, or direct them to our website for more information.  We would be happy to send hard copies of our brochure to your office if interested.