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Referring Providers

Referral Form

This form is intended only for clinical referrals. If you would like to submit a self-referral or are requesting an appointment on behalf of a family member or friend, please CLICK HERE.

If you would prefer to speak with our intake staff and schedule a referral for any of our locations, please call 855-407-6661.

Referral Form

Please note:

  • We accept most forms of insurance, including Medicare and Medicaid.
  • At this time we are not accepting patients who have been hospitalized more than twice in the past calendar year.
  • We do not offer detox services and cannot wean patients off of medications.
  • Please make sure contact numbers are up to date and patients are aware we will be calling.

Patient Demographics

Address:

Reason for Referral

Insurance Information

Tropical Storm Isaias is headed towards the Carolinas

Tropical Storm Isaias is headed towards the Carolinas. Please note that we plan to be open for appointments; however, be aware that power outages may be widespread which may impact telehealth and other appointments. We may not know until the last minute in all of our locations on Tuesday. Please be patient. We will waive missed appointment charges on Tuesday, August 4th in light of complications from the weather. If you and your provider are unable to connect, we will reach out to reschedule your appointment as soon as possible.