Fax or E-mail

Download, Print and Complete our simple Referral Form, and Release of Information forms. Once completed, you may either fax to 602-788-1119 OR scan and send via email to


with subject line: Referral Form. (Please note our forms are in .pdf format and will require a pdf viewer. If the computer you are accessing this form with does not have the software, you can download Adobe Acrobat Reader, for free, here.


You may call the administrative office directly at 602-788-1116 to request a referral form, or you may click below to download, print and complete the form.