Referral Form

Discovering the services we offer is just a step away!

Simply input your personal information, your insurance information, and what services you are seeking, and we’ll swiftly verify your benefits. This quick process enables you to effortlessly explore which services are covered under your policy, making it easier for you to take the next step in accessing our offerings. There is no commitment or fee for completing this form. We highly recommend you review your full insurance benefits summary or call your insurer for clarification.

Referrer Information

Relationship to Client(Required)

What services are you looking for?(Required)

Outpatient Therapy

Children’s Outpatient Therapy

Behavioral Health Home

DEEP

Substance Use Support

What can we help you with?

Review The AWS Services Available

Referrer First Name(Required)

Referrer Last Name(Required)

Referrer Email(Required)

Reason for Referral(Required)

Insurance Information

You're on the path to receiving the support you need. Please share your insurance details with us to verify your current benefits. Based on the information from your insurance company's portal, we'll provide you with a good-faith estimate.

Understanding insurance benefits can sometimes be detailed. We encourage you to reach out to your insurers directly or review your complete benefits summary for a comprehensive understanding of your coverage.

Primary Insured Relationship to Client

Primary Insurance

Primary Insurance ID

Primary Insurance Group ID

Primary Insured First Name

Primary Insured Last Name

Primary Insured Date of Birth

Primary Insured Address

Primary Insured Address 2

Primary Insured City

Primary Insured State

Primary Insured Zip Code

Hidden

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Insurance

Add Second Insurance Provider

Second Insurance Provider

Secondary Insured Relationship to Client

Secondary Insurance

Secondary Insurance ID

Secondary Insurance Group ID

Secondary Insured First Name

Secondary Insured Last Name

Secondary Insured Date of Birth

Secondary Insured Address

Secondary Insured City

Secondary Insured State

Secondary Insured Zip Code

Hidden

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Tertiary Insurance

Add Third Insurance Provider

Third Insurance Provider

Tertiary Insured Relationship to Client

Tertiary Insurance

Tertiary Insurance ID

Tertiary Insurance Group ID

Tertiary Insured First Name

Tertiary Insured Last Name

Tertiary Insured Date of Birth

Tertiary Insured Address

Tertiary Insured Address 2

Tertiary Insured City

Tertiary Insured State

Tertiary Insured Zip Code