Referral form for Physicians and Clinicians

We are accepting new patients. However, each prospective patient must complete a 15-minute discovery call with one of our psychiatrists to confirm that we can provide appropriate care. Please complete the referral form below and advise your patient that our office will contact them within 2 business days to schedule a discovery call.

Salutation

Primary Reason for Referral

Patient Info

Patient Age

Parent / Guardian

Relationship to child