Testing Page - Guardian Recovery

Guardian Recovery | Referral Form

"*" indicates required fields

Hidden

Seeking Help for Self or a Loved One

Hidden

Caller Relationship

Your Name:*

First Name Last Name

Your Phone Number:*

Your Email:*

Title:*

Organization, please specify branch if relevant:*

If you can't find the organization above please post it here.

Patient's Name:*

First Name Last Name

Patient's date of birth:*

Patient's Preferred Location for Services:

Patient's Address:*

Street Address City State / Province / Region ZIP / Postal Code

Patient's Email:*

Patient's phone number:*

Patient's Insurance Type:

Patient's Insurance Provider:

Patient's Member ID:

Insurance Card Upload (Front of Card):

Max. file size: 256 MB.

Insurance Card Upload (Back of Card):

Max. file size: 256 MB.

What is the patient's primary need?*

Mental Health

Substance Abuse

Which level of care are you recommending for the patient? (select all that apply)*

Detox

Residential Treatment

PHP

IOP

Virtual IOP

Outpatient

Tell us a little more about the patient and their current needs:

Additional Paperwork Upload

Drop files here or

Max. file size: 256 MB, Max. files: 4.

I give or have obtained any necessary consent/authorization prior to disclosing the health information above. The patient is aware of this referral and is expecting Guardian Recovery to contact them directly via phone, voicemail, SMS/text, and email as appropriate.*

Yes

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.