Submit a Partner Referral | AriseVida Care

Your organization

Who should our admissions team coordinate with about this referral?

Organization name

Your name

Work email

Direct phone

Role or department optional

Provide a work email, a direct phone number, or both — we use them to follow up with you about this referral.

Person being referred

The basics our team needs to open the referral. Only the name is required.

First name

Last name

Date of birth Required

Helps our team match records if the person has been seen before.

Preferred language optional

EnglishSpanishOther

How should our team make contact? Required Contact the person directlyOur admissions team reaches out to the person using the details below. Coordinate through our organizationWe work through you or a contact at your organization — no direct details needed.

Care needs, insurance and documents

Share what you know. Our team can help determine the right level of care.

Requested services Choose at least one

Medication TreatmentMethadone, Suboxone or naltrexone with recovery supportIntensive Outpatient ProgramStructured group and individual outpatient treatmentIOP with Supportive HousingOutpatient treatment with housing support, subject to availabilityMental Health and Psychiatric CarePsychiatric evaluation, medication management, therapyDeep TMS TherapyNon-invasive treatment for depression, anxiety and OCDNot sure / Help us determineNot sure / Help us determine

Reason for referral

Please do not paste detailed medical records here — documents can be attached below.

0/1000

Insurance Required

Has insuranceUninsured or self-payNot sure / Help us determine

Supporting documents optional

Referral paperwork, assessments or care-coordination documents. PDF, JPG, PNG, DOC or DOCX · up to 4 files · 4 MB each · 12 MB total. Files upload privately as you add them.

Review and submit

Check each group and edit anything that needs a change. Editing keeps everything else, including uploaded documents.

I understand that this form is not for medical or psychiatric emergencies. For emergencies, call 911. For crisis support, call or text 988.

Referral details and documents are stored privately and reviewed only by authorized admissions staff. See our HIPAA Notice and Privacy Policy.

Your referral has been received.

Our admissions team will review the information and follow the contact preference you selected.

Reference

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