Clinic Forms & Waivers

If you are a physician and referring a new patient, please complete and fax the referral form, along with any applicable evaluation/procedures, recent office notes, hospital/rehab notes and/or specialty visits related to diagnosis. 

Physician Referral Form

This form is to be completed by the referring agency or physician, most commonly your Primary Care Physician.

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Maroon background with white text that reads "Child Intake Form" and a faint abstract leaf design.

Please complete this intake for children under the age of 18.

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Maroon background with white text that reads "Adolescence & Adult Intake Form" and a faint abstract leaf design.

Please complete this intake form for adults and adolescence over the age of 18.

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