Referral Forms To make a referral, please complete the appropriate form below. If you prefer, you can download a PDF of the form and fax it to us at 1-855-704-4080. Thank you. Insurance Referral Form: Download Medical Referral Form: Download Medical Referral Form Medical Referral Form If your doctor has recommended an assessment, please fill out this form. Insurance Referral Form Insurance Referral Form If you have insurance coverage for therapy services please fill out this form. Contact and Information Form Contact and Information Form Please submit this form to request information about our services, or to leave feedback or suggestions.