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.

Patient First Name
Patient Last Name
Patient's Email (or Guardian's Email if Patient is a Minor)
Patient (or Guardian's Phone if Patient is a Minor)
  • 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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