Provider Referral Form

We are here to help those struggling with addiction and mental health begin their road to recovery and strive to offer a quick referral process to get that journey started as soon as possible.

Please fill out the form below to begin the referral for your client/patient. A member of our admissions team will reach out directly to gather more information and set up an assessment. IF this person is still in the hospital, the admissions team will contact you to walk through next steps.

We are honored you chose Integrative Life Center.

NOTE: Upon completion of this form you will be immediately emailed by the system, and able to upload medical records to that email for a more secure send to our team.

Patient / Client First Name*
Patient / Client Last Name*
Patient / Client Phone Number*
Patient / Client Email*
Patient / Client State of Residence
Patient / Client's Date of Birth*
MM slash DD slash YYYY
Referring Organization*
Referred By*
Referring Party's Phone Number*
Email -||- Referring Party Email (*for Sending Records*)*
Insurance Company
Member ID Number (Policy)
Group Number
Additional Notes (optional)
How did you hear about ILC?

Provider Referral Form

Start Your Healing Journey Today

Nashville

What we treat

Our treatment programs

FOLLOW US ON

accreditations

Give Us a Call