Due to the high volume of requests, a Counseling Referral Form is required to make an appointment.
This form must be completed in its entirety by the identified patient's Primary Care Provider (PCP). 
Once received, the patient will be contacted within 48 hours.

Instructions:  Simply click the link below to download the form
Complete, sign and fax the referral form to: 855-420-6895

Feel free to also call the Intake/Referral Line at 857-424-3154