New Client ReferralSimply fill out the referral form and we’ll be in touch soon. Client Name * First Name Last Name Date of Birth * Referring agency and person * Parent/Guardians if minor Email * Phone * (###) ### #### Full Address What insurance are you covered by? * * We do accept some Medicaid plans, but will need to verify benefits. Presenting Problems/Diagnosis * Thank you for the referral. A member of our team will reach out to you within 24-48 business hours. Have any questions before we contact you, please call our office at 704-691-9415.
