Request referral

Refer a patient

Thanks for trusting us with your patient’s care. Submit the form below and our team will reach out to them to schedule a consultation.

Important: This form is not for urgent matters. Our team will contact the patient within 1–2 business days. For a faster response, call (302) 494-4666. If the patient is in crisis, call or text 988 or call 911.

Referring provider

Referring organization *

Referrer name *

Referrer email *

Referrer phone *

NPI (optional)

Patient information

Patient first name *

Patient last name *

Patient phone *

Patient email (if available)

Patient state *

Patient’s preferred language

Best time to reach patient

Referral details

Treatment requested * One-Day Program (self-pay)Traditional multi-week course (insurance, from early 2027)Evaluation — recommend the best option

Additional context (optional)Non-clinical details that help with coordination (e.g. scheduling constraints). Please don’t include diagnoses, medications, or other medical information. We’ll collect those securely during intake.

Refer a patient

Referring provider

Patient information

Referral details

Thank you for your referral!