Referrals

Referrals

Patients can also be referred by calling our care team directly at 1-800-567-LIFE (5433)

If you need more physical materials for your workplace or to hand out to patients, please visit https://totallife.com/materials/
Please choose from the following options:*

New Patient Referral(s)Support with an Existing Referral
For support with existing referrals please submit a ticket:

Submit a Support Ticket

You can also send inquiries at support@totallife.com or by calling our care team directly at 1-800-567-LIFE.

Referrals

Patients can also be referred by calling our care team directly at 1-800-567-LIFE (5433)

If you need more physical materials for your workplace or to hand out to patients, please visit https://totallife.com/materials/
Your First Name*
Your Last Name*
Your Position*
Your Email*
example@example.com
Referring Organization Type*
Referring Doctor/Organization Name*
Referring Organization Fax Number
Please enter a valid phone number.
How any patients are you referring?*

Single patientBulk upload

Single Referral

Please input the patient details. Patients can also be referred by calling our care team directly at 1-800-567-LIFE
Patient First Name*
Patient Last Name*
Patient Email*
Please enter a valid email address
Patient Phone Number*
Please enter a valid phone number
Date of Birth*

MonthDayYear
Home State*
Medicare Beneficiary Identifier (MBI)
Please enter the patients MBI number (optional)
Patient's Primary Care Physician (PCP)*
Please enter the patients PCP
Do You have the Patient's Insurance Information Available?*

YesNo
Insurance Plan
Insurance Plan ID
Supplemental Insurance Plan
Supplemental Insurance Plan ID
Does the Patient Have a Power of Attorney?*

YesNo
Power of Attorney Name

First NameLast Name
Power of Attorney Email
example@example.com
Power of Attorney Phone Number
Please enter a valid phone number.
Does the Patient Speak English*

YesNo
Patient's Primary Language
Who should we contact to book the appointment?*

PatientPatient's Power of AttorneyYou (Referrer)Patient will reach out to Total Life
Notes
Include notes on their mental health status, reasons for referral, or any specific therapy requirements.
Bulk Referrals

Please follow the steps below to refer patients in bulk
Please use this template to upload bulk referrals.

Fill in all fields for each client and upload the file below.
File Upload*

Cancelof
Should be Empty:

For support with existing referrals please submit a ticket: