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Please fill out the referral form below. This form is fully HIPAA compliant and the information gathered will allow us to verify insurance benefits and will expedite the intake process. As soon as we have verified benefits we will call you back in order to schedule an appointment with one of our therapists. Please allow 24-48 hours for us to get back to you. Thank you. 


The boxes marked (*) are required fields.



(If "Self-Pay" type in N/A on required fields)

Do you have more than one insurance plans?

(If "Yes", please fill out fields below)

IMPORTANT: Please include a copy of your Insurance Card and ID (front and back) 

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Thanks for submitting! We will attempt to contact you within the next 24-48 hours in order to schedule your appointment.

Contact Us!

If you have questions about self-pay rates, services, etc. feel free to ask here. Please leave your name, contact email address, and a good phone number that we can call back. We will try to get in touch with you within 24-48 hours. If you do not get an e-mail back from us within that time frame, please check your junk mail, as many have reported this to be an issue. Thank you.  

Thanks for submitting!

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