Appointment Request & Referrals

Appointment Request & Referral Form
Please complete this brief form to help us schedule your appointment. We will contact you by phone within 48 business hours.
Are you a medical professional referring a client to our agency?*

YesNo
Referral Information
Referring Agency/Provider Name
Referring Office Phone Number

Area CodePhone Number
Release of Information Upload

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Cancelof
Medical Record/Referral Upload

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Other Information Relevant to Referral
Potential Client Information
Client Name*

First NameLast Name
Parent/Guardian Name if different from Client

First NameLast Name
Client Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
Insurance Company Name or Self-Pay*
Telehealth or In-Person Preference

TelehealthIn-PersonOpen to Either Option
Preferred Office Location

MagnaNorth Salt Lake/BountifulSouthtowne-SandyTaylorsvilleTooeleWest Jordan
Brief summary of what you are looking for.
Client E-mail
*FOR OFFICE USE ONLY
Ex. Client Transfer, Internal Referral, etc
Should be Empty:

Appointment Request & Referral Form