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
Format: (000) 000-0000.
Patient's Sex (as listed on insurance policy)
Patient's Gender Identity
Patient's State of Residence

Other
Service Requested
Patient's Reimbursement Type

Other
Arizona Insurance Plan
Colorado Insurance Plan
Massachusetts Insurance Plan
Virginia Insurance Plan
Insurance Plan
Referring Provider's Information
Referrer's First Name
Referrer's Last Name
Referrer's Title
Referring Practice Name
Referrer's Email Address
Referrer's Phone Number
Format: (000) 000-0000.
Referrer's Fax Number
Format: (000) 000-0000.
If this your first time referring to Third Space?
Diagnosis, if applicable
Type(s) of Therapy and/or Psychiatry Recommended
source
Communication Preferences: Consent to receive these communications is not a condition of partnering with or receiving services from Third Space. If you do not opt in, you will only receive notifications confirming receipt of a referral, and we will continue ongoing care coordination and care updates — but only where a valid Release of Information (ROI) is in place for your patient. You may revoke your consent at any time by unsubscribing from email, calling (833) 244-4878, or contacting us at opt-out@talkthirdspace.com
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Refer a Patient to Third Space Therapy

Patient's Information

Referring Provider's Information