Professional Referral Page

Use the form below to submit a professional referral to our clinic.

If you have a fax to send, our fax number is:


  • Please enter the client's name.
  • If the client is a minor, please list the parent / guardian for us to contact.
  • Please name the referring clinician and / or office.
  • Please list the contact person (if different from clinician)
  • Please provide the best phone number if we need to contact you
  • Please add anything else that would be helpful for us to know.