Stronger Together!

Provider Referral Form

Important information to know before submitting the following form…

We currently accept the following insurances:

Anthem BCBS (commercial and Medicaid), Aetna, Optum and UHC (commercial and Medicaid), Cigna, Medical Mutual, Buckeye Medicaid, and Caresource (commercial, Medicaid, and MyCare).

Once you submit the form, we will reach out to the client within 24 hours. Our goal is to schedule the client for an intake in 1-2 weeks from initial contact.

We offer daytime, afternoon, evening and weekend appointments.

Client's Name

First Name

Last Name

Client's Phone Number or Email

(###)

###

####

Client's Insurance

Reason For Referral

Referring Provider

Any Additional Important Information?

Stronger Together!

Provider Referral Form

Our therapists focus on anxiety and life transitions, aiding adults like you in conquering the stress of "adulting." We empower you to transition into your new phase of life with the confidence needed to tackle the world head-on.

*******