For Providers

Refer a Client to Primary Behavioral Health

Please complete the form below. We'll contact your client within one business day, same day for urgent referrals, and keep you informed throughout intake.

Referring Provider

Provider Name *

Credentials (e.g. LCSW, LPC, MD) *

Organization / Practice *

Phone *

Email *

Fax (optional)

Provider NPI (optional)

Client Information

Client First Name *

Client Last Name *

Client Date of Birth *

Client Phone *

Client Email (optional)

Insurance Provider *

Insurance Member ID (optional)

Clinical Information

Primary Diagnosis *

Current Level of Care *

Reason for Referral *

Is the client aware of this referral? *

Yes

Urgency *

Would you like to remain the client's primary therapist during the program? *

Yes

Additional Notes (optional)

Consent & Submission

I confirm that I have obtained appropriate consent from the client or their legal guardian to share this information for the purpose of coordinating care. This referral is made in accordance with HIPAA regulations and 42 CFR Part 2 where applicable.

Provider Signature (type full name) *

Date

2026-07-18