Provider Referrals

Making a provider referral to one of our programs

Providers are welcome to refer patients to our Partial Hospital Program or Intensive Outpatient Program. To do so, please complete the secure form below and also let us know when to expect a completed application from the patient’s family.

If you reach out to us regarding a referral, please send parents to our Program Application page and request that they also complete an application.

"*" indicates required fields

Provider’s Name*

First Last

Practice Location*

Provider's Email*

Provider's Phone*

Child’s Name*

First Last

Reason for Referral

Child's Date of Birth*

Child's Social Security Number

Medicaid Number

Ethnicity/Race

Gender*

Parent/Guardian Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Best Way To Reach Parent/Guardian

Call

Text

Current School Or Childcare Center (If Applicable)

Current Therapist Or Case Manager (If Applicable)

Current Therapist Or Case Manager's Phone Number

CAPTCHA

This field is for validation purposes and should be left unchanged.

PLEASE NOTE

It is very important that parents also take the appropriate steps for admission. Applications completed by parents are required for the admissions process to begin. As we are often on a waitlist at Bright Path, we use the date of the completed application to order that list. Once the application is received, our admissions team will connect with the family and walk them through the process.
We’re also here to help, whether that’s providing more information, discussing the clinical needs of a particular case, or getting you pointed in the right direction.

Application For Parents and Teens