Patient Referral

Patient's Name(Required)
MM slash DD slash YYYY
Patient's Gender(Required)
Type of treatment they are seeking
Which office would they prefer?

Insurance Information

This is optional. However, if you provide this information, we are able to authorize their plan and get them seen more quickly.
We are in network for most major insurers. However, we are not in network with Medicaid. We accept Aetna, BCBS, Cigna, CBHA, MedCost, Medicare, Magellan, and United Health Care.
Make sure to include the two numbers at the end (after the hyphen) if applicable.

Your Information


Thank you!

We appreciate your referral and will reach out to them to schedule.