Refer a Patient

For physicians, clinicians, and inpatient organizations — refer a patient to Revive Life using the form below.

FOR PROVIDERS & FAMILIES

Submit a Patient Referral

Physicians, clinicians, inpatient organizations, and family members can refer a patient to Revive Life Mental Health & Outpatient Addiction Rehab Center.

If you are referring on behalf of an organization, include your organization name and your contact details so our team can follow up with you.

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Referral Form

Required fields are marked. Organization details appear only when you select Organization.

"*" indicates required fields

Facebook

This field is for validation purposes and should be left unchanged.

Referring Party

Tell us who is making this referral.

Referrer type*

Organization

Family member

Select Organization if you are a physician, clinician, clinic, hospital, inpatient program, or a community organization (such as a DUI program or college counseling center).

Referring organization name*

Referring person name*

Referring person title*

Referring person/organization's contact number*

Phone number where we can reach the person or organization making this referral.

Patient Information

Patient name*

Patient date of birth*

Patient phone*

Patient email

Reason for referral*

Please specify other reason*

Diagnosis / additional clinical details

Urgency*

Routine

Urgent

Choose Urgent if the patient needs contact within 24–48 hours.

Insurance provider

How to Reach You

We will use this to follow up about the referral.

Best way to reach the referring person*

Phone

For clinicians: best way to reach the referring clinician. For family members: best way to reach you.

Referring person email*

Consent*

I confirm I have the patient's (or legal guardian's) permission to share this information for referral purposes.

REFERRAL PROCESS

How Referring Works

Sending a referral should be simple for you and your patients. Our intake team takes it from here.

Submit the referral

Share patient details and clinical context using the secure form on this page.

We contact the patient

Our intake team reaches out promptly to verify benefits and discuss the best level of care.

Care begins

The patient is scheduled for outpatient mental health or addiction treatment at Revive Life based on their assessed level of care.

Refer a Patient

FOR PROVIDERS & FAMILIES

Submit a Patient Referral

Referral Form

Referring Party

Patient Information

How to Reach You

REFERRAL PROCESS

How Referring Works

Submit the referral

We contact the patient

Care begins

Schedule consultation with Revive Life!

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