Expedited Referral Form

Estimated time to complete : 1-3 minutes

This form is for referral use by medical or mental health professionals only

Providers - Please advise your patient that we will contact with them within 2 business days, using the information provided you here, to arrange their intake and first appointment at their earliest convenience. 

Note that due to the need for intake paperwork that must be completed and reviewed prior to their first session and to allow them time to call their Insurance company to obtain insurance benefits prior to their first appointment we cannot offer same day first appointments.

This information is kept confidential and will not be shared.


Select one or more services.


Note: The nature of email communication means confidentiality can not be guaranteed.


You MUST click the continue button below to submit the data.