FIND YOUR THERAPIST
New Patient Referral Form
Use our secure form to refer your patients to UpLift for therapy or psychiatric services
ABOUT THE PROVIDER
ABOUT THE PATIENT
State of Residence*
Date of Birth (MM/DD/YYYY)*
What is the referral for?*
Psychiatry, therapy or both
Information to facilitate match
We have therapists that specialize in many areas, please provide any relevant details to help us facilitate the best possible match
Thank you! We have received your submission and one of our Practice Consultants will contact you within 24 hours.
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Terms of Service
If you are considering suicide or if you or any other person may be in danger, please call or text 988 (24-hour suicide and crisis lifeline) or call 911.