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Attention: Healthcare Providers – Need to send us a referral?

Please fax to (913) 346-6309 or use the form below to upload records.

Refer a Client Using the Form Below

We frequently receive referrals from primary care practices, other medical practices, and behavioral health professionals. To simplify the process for you, we have created the form below which enables you to make a referral and to upload patient records (if desired). We are very conscientious about following up on referrals, and we will send you updates about the client’s treatment plan and progress.

"*" indicates required fields

Client Name*

First Last

Client's Phone Number*

Referring Provider's Name*

First Last

Referring Provider's Phone Number*

Provider's Practice or Facility Name*

Comments*

Please let us know briefly how we can help...

Upload Client Records Below (if desired)

Drop files here or

Max. file size: 128 MB.

Email

This field is for validation purposes and should be left unchanged.