Make a Referral

We welcome client referrals from other community providers and partners. Please fill out this form and submit it when complete. The form can also be printed and faxed to the client’s preferred office. If referring more than one client in the same family, please list all names on one form and submit only once.

ACT Referrals require a specific form, which can be found here. Please note that you must include supporting documentation with the referral form.

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Referral Form

Please make a referral by completing the following fields and clicking submit, or print off the form and fax to the client's preferred clinic location. If referring more than one client in the same family, please list all names on one form and only submit once.