Refer a person to Affect's program Affect Therapeutics

New Patient Referral
We are excited to work with you to help your referral receive high quality care. Please read the following before submitting a referral:
- This form is designed to be filled out by someone making a referral on behalf of the intended member. Affect does not accept anonymous referrals, please do not input information of someone who does not know you are doing so.
- If you are seeking treatment for yourself, click here and fill out the form.
- To provide a referral over the phone, call (888) 594-7015. Our Treatment Consultants will ask you the information below and can answer any questions you may have.
Referrer Name*
First NameLast Name
Referrer Role*
Medical ProviderCase WorkerLawyerParole OfficerFriend/FamilyOther
Organization*
Referrer Phone Number*
Please enter the best number to reach you.
Referrer Email*
Please enter the best email address to reach you.
Patient Info
The below information helps us determine if we can enroll the member, and how to contact them. Do not provide someone else's contact information without their permission.
Patient Name*
First NameLast Name
Date of Birth*
MonthDayYear
Date
State of residence*
Cell Phone Number*
Please enter the best phone number to reach your referral (the intended patient).
Mathing
Email
Please enter the best email address to reach your referral (the intended patient).
What is the primary substance they need help managing?*
AlcoholMethCrackCocaineWeed / CannabisHeroinFentanylRx PainkillersRx stimulants/ADHD medsOther Opioids
What is the patient’s insurance type?*
Who is the patient’s insurance provider?*
Reason for referral*
Additional Information
Phone number ERROR: The phone numbers should NOT match!
If you do not know the phone number of the person you are referring, please leave that field blank and submit this form with their email address.
We need a minimum of 1 way to contact your referral, if you do not have any contact information for them, please get it prior to submitting this form.
Email address ERROR: The emails you entered for yourself and your referral should NOT be the same.
If you do not know the email address of the person you are referring, please leave that field blank for them and submit this form with their phone number.
We need a minimum of 1 way to contact your referral, if you do not have any contact information for them, please get it prior to submitting this form.
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New Patient Referral

Patient Info