Refer a Patient to Third Space Therapy

Refer a Patient to Third Space Therapy

Thank you for referring your patient to Third Space Therapy. To help us provide the best possible care, please complete this referral form with your patient's contact information and insurance details. We'll reach out to schedule their first appointment within 12-24 hours.
Patient's Information

Please note: We need the patient's email to send them a link to our patient portal to complete our intake & consent forms, and attend their tele-therapy session.

If the patient does not have an email address, please share the email of a parent, guardian, or caretaker who can coordinate the appointment on behalf of the patient.

We're unfortunately unable to accommodate patients without an email address at this time.
Patient's First Name*
Patient's Last Name*
Patient's Preferred Name (optional)
Patient's Date of Birth*

MonthDayYear
Patient's Email Address*
Patient's Phone Number*
Patient's Sex (as listed on insurance policy)*

FemaleMale
Patient's Gender Identity*
Patient's State of Residence*

ArizonaColoradoMassachusettsVirginiaOther
Patient's Reimbursement Type*

MedicaidMedicareCommercial/PrivateTRICARESelf-PayOther
Arizona Insurance Plan*
Colorado Insurance Plan*
Massachusetts Insurance Plan*
Virginia Insurance Plan*
Insurance Plan*