Opt2Restore Referral Inquiry Form

Full Name (Required)*

First NameLast Name

Email (Required)*

example@example.com

Phone Number (Required)*

Please enter a valid phone number.

Who are you completing this form as? (Required)*

Preferred Follow-Up Method (Required)*

Location of Patient / Service (Required)*

Street Address

Street Address Line 2

City

Postal / Zip Code

Service Type Needed (Required)*

How Soon Do You Need Help?(Required)*

Brief Description of Referral or Collaboration Inquiry (Required)*

Acknowledgment (Required)*

This inquiry is for professional collaboration or referral purposes only and does not schedule patient appointments.

HIPAA PRIVACY NOTICE

This form is submitted through a HIPAA-compliant, encrypted platform.
Information provided will be used solely for care coordination, safety planning, and clinical review by Opt2Restore LLC and will not be disclosed except as permitted or required by law.

All information is handled in accordance with applicable federal and New York State privacy, security, and confidentiality regulations.

This referral interface is part of the licensed Opt2Restore™ C.A.R.E. Model™ governance framework for clinical and environmental safety planning and coordinated aging-in-place support.Submission of this form does not establish a provider–patient relationship and is intended for professional coordination purposes only.