Referral Form

We have created this form in an effort to make referrals as simple and convenient as possible. If we can be of further assistance, please do not hesitate to reach out at [email protected] or 480-272-8450.

First Name *

Patient First Name

Last Name

Patient Last Name

Email *

Patient's Email (or Guardian's Email if Patient is a Minor)

Phone *

Patient (or Guardian's Phone if Patient is a Minor)

Is the Patient a Minor? *

Yes

No

If the patient is a minor, what is the parent/guardian's full name?

What Services Is the Patient Being Referred For? (Select all that apply) *

Outpatient Psych / Med Management

MAT Services (Medication Assisted Treatment)

Outpatient Therapy

IOP Program

TMS Treatment

Spravato / Ketamine

Other (if so, list in "Message" below)

Records Upload

Referring Provider

Aurora Behavioral Health
Banner Behavioral Health
Banner Hospital
Copper Springs
Core Recovery
Maricopa County Adult Probation
MyDrNow
ValleyWest
Village Medical
Quail Run
Other (Please list in message)
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Referral First Name

Referral Last Name

Referral Phone number

Referral Email

Message