Refer a Patient

If you feel your patient could benefit from Telehealth Outpatient Mental Health Treatment, please complete the information below.

Required Field (*)

Is the Client Aware of and Agreeable to this Referral?

Yes No

Is the Referral Urgent?

Yes No

Client's Full Name

Client's Date of Birth

Client's State

Client's Phone Number

Client's Email

Client's Preferred Language

If Selected "Other" Please Specify

Best Way to Contact Client

Call Text Email

May We Leave a Message?

Yes No

Formulario con Título

Referring Agency

Referrer Full Name

Referrer Email

Reason for Referral

Primary Insurance Type of Client

Medicaid Commercial

Primary Insurance Carrier of Client

Member ID of Client

Group ID of Client

Policy Holder Name of Client

If you, your child, or someone you know is in crisis, call 911, go to the nearest emergency room, or reach out to the following national resources. You’re never alone.

Call 988 to reach a 24-hour crisis line.
Text 741741 to reach the Crisis Text Line.

Additional resources here

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