Licensed Mental Health Referral Form

  • CarryMe Health Therapy Intake Form

    Submissions will be responded to in 1 business day. Therapist match (based on insurance, state, focus areas) in less than 5 business days.
    • Individual Information 
    • Format: (000) 000-0000.
    • Provider Information (if you are the patient, this section is not required) 

    • Thank you and we look forward to supporting you. 

      We will reach out within 1 business day, matching you with therapists (by insurance, state, and focus areas) in less than 5 business days.

      If experiencing a mental health crisis or in need of emergency services for you or your family: Call 911 or go to your nearest emergency room.

      National Suicide Prevention Hotline (24/7): Call 988
      Postpartum Support International Helpline (8AM-11PM EST): Call 1-800-944-4773 (4PPD)
      National Maternal Mental Health Hotline (24/7): Call 1-833-852-6262 (TLC-MAMA)

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