Make a Referral

If you know someone who could use support in overcoming addiction or unwanted habits, consider referring them to us. Remember, therapy with Anonymous Health is covered by Medicaid and most health insurance.

Patient Information

Patient First Name *

Patient Last Name *

Patient Phone Number *

Patient Email *

Patient State *

Preferred Call Time

Reason for Referral *

This person is currently enrolled in substance use disorder (SUD) or medication assisted treatment (MAT) services

This person is currently in withdrawal

Referrer Information

Referrer First Name

Referrer Last Name

Referrer Email *

Referrer Phone Number *

Organization

We'll be in touch as soon as possible after your submission.