By clicking 'Submit' you agree that you are either the person identified above, the parent/legal guardian of the person identified above, or as the referring agency, you have obtained the appropriate release of information needed to make this referral.

**If you are an agency referring a patient for services, please note that a signed Release of Information must be included with the referral before we can contact or update you on the status of the referral.  Release of Information forms can be located at the bottom of this page. Please feel free to upload (located at the end of the new patient referral form below), fax (888-974-6195), or email (staff@dawnahaswell‐ the completed Release of Information. 

​**DISCLAIMER: This form should NOT be used in crisis/emergency situations (e.g. if you are currently experiencing thoughts of suicide, homicide, or self-harm). If you are experiencing a life threatening emergency please contact 911 or go to your nearest emergency room for immediate assistance. If you or someone you know is feeling suicidal or in an emotional crisis, you can also contact the National Suicide Prevention Lifeline at 1-800-273-TALK.

New Patient ​​Referrals

Patient Forms