Thank you for partnering with us to care for your LGBTQ+ clients.
Please complete this short HIPAA-compliant form to refer your client to Allswell.
We offer 1:1 and group therapy for LGBTQ+ adults and accept most insurers. We’ll reach out to your client within 24 hours of your referral.
Please note: We are unable to accept clients currently experiencing an acute mental health crisis (e.g., self-harm or suicidality). By submitting this referral, you confirm that the client meets these criteria.
Client First Name
*
Client Last Name
*
Client State of Residence (We only support MD at this time)
*
Client Phone Number
*
Please enter a valid phone number.
Client Email (Optional)
example@example.com
Referring Provider First Name
*
Referring Provider Last Name
*
Referring Provider Phone Number
*
Please enter a valid phone number.
Referring Provider Email
*
example@example.com
Submit
Should be Empty: