For Providers/Submit a Referral

Submit a Patient Referral

Help your patients access expert mental health care. Complete the form below or use one of our alternative submission methods.

Most patients seen within 5-7 daysConfirmation within 24-48 hours

Online Form

Fastest option - submit below

Fax Referral

(209) 290-3019

Online Referral Form
All fields marked with * are required. We will contact the patient within 24-48 business hours.

Referring Provider Information

Patient Information

Referral Details

Printable Referral Form
Prefer to fax? Download our referral form.
Download PDF FormPrint Form

Fax to: (209) 290-3019

Need Help?
Our team is here to assist with referrals.

Mon - Fri: 8:00 AM - 5:30 PM EST
Response within 24-48 business hours

Important Notes

  • We accept patients ages 11 and older
  • We do not provide court-ordered evaluations
  • Emergency/crisis referrals should call 988 or 911
  • Patient must reside in Georgia for telehealth
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Experiencing a Mental Health Crisis?

If you or someone you know is in immediate danger, please call 911 or go to your nearest emergency room. For crisis support, call or text the 988 Suicide & Crisis Lifeline.

Call 988Crisis Resources