Houston Mental Health Referral Form for Healthcare Providers

We know you care about your patients. We're excited to work with you to help them get better faster.

Provider First Name*

Provider Last Name*

Provider Phone*

Provider Email*

Provider Fax

Name of Practice

Patient First Name*

Patient Last Name*

Patient Phone*

Patient Email

Patient DOB*

Reason For Referral*

Ketamine Therapy Medication Consultation

Patient's Conditions and Diagnosis*