Submit a Referral

We value collaborative relationships with medical and psychiatric providers, as well as mental health and allied health professionals. Azalea Mental Health does not provide emergency or crisis services. Submitting this referral allows our office to contact your client for an initial phone screen, and is not a guarantee of services. By completing this form, you confirm that the client has provided explicit consent, is aware of the referral, and to the best of your knowledge, is appropriate for outpatient care.

Referring Provider's Contact Information:

First Name

Last Name

Your Contact Information [if not provider]

Client's First & Last Name:

Client's Contact Information

Please include any relevant clinical information.

You may fax any additional information to (844) 770-0399

Would you like to be notified of the outcome of this referral?

Yes, Please.

No, Thanks.

Client's State of Residence:

Please indicate if you are recommending any specific modalities, or if you would prefer client to be seen by a specific therapist.