Refer Patients

Please use the form below to refer a patient to Living and Balance Wellness Center.


Patient Referral Form

Client Referral Form

Formulario De Referencia Del Paciente


Referring Agency Representative Information


Client Information/Información del Paciente


Parent/ Guardian Information (If Applicable)

Información de padres/tutores (si corresponde)


Medical Insurance Information/Información de seguro médico


Reason for Referral

(To be Filled Out by Referral Agency Representative)


FOR PROFESSIONALS – REFERRALS & FORMS

We appreciate you recommending us to your clients. We are dedicated to giving them the best treatment. Additionally, we are committed to supporting you in providing clients with mental health and substance addiction concerns with better care.  You may need to download the free Adobe Acrobat Reader. The tool below is available to help accomplish this:

The Mental Health Referral Form is a softcopy of our standard referral form online that you can use to recommend patients to us. This form can also be completed online and sent to referrals@livingandbalance.com.
(Please be advised that this form is not required, and you can also outreach to the Referral team at referrals@livingandbalance.com for any questions regarding referrals.)