Referral Request Form

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Use this form if you would like to contact REVA to request a referral. REVA will contact you at the email address you provide to set up an appointment to discuss your needs.

Email *

Name *

This is not an emergency. If it is an emergency, please immediately call 911.
*

I confirm that this is not an emergency.

Required

REVA does not establish a doctor-patient therapeutic relationship. REVA merely provides referrals for mental health care.
*

I understand that REVA does not establish a doctor-patient therapeutic relationship.

Required

While REVA makes every effort to find appropriate referrals, you are solely responsible for vetting the referrals to make sure they are appropriate for you.
*

Yes, I am solely responsible for vetting referrals to make sure they are appropriate for me.

Required

While REVA makes every effort to find appropriate referrals, you understand that we may not always be able to do so.
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Yes, I understand that REVA may not be able to find an appropriate referral for me.

Required

In order to make effective referrals, REVA will need to collect relevant health information to assess your need. The information we collect will be governed by our Privacy Policy.
*

Yes, I consent to sharing relevant health information to help make an effective referral.

Required

I have read and accept REVA's Terms of Service.
*

Yes, I have read and accept REVA's Terms of Service.

Required

A copy of your responses will be emailed to the address you provided.

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