PATIENT REFERRAL FORM



Patient Referral for Providers

Have a patient in need of treatment? Fill out this form.

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Patient's Date of Birth(Required)


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Our mission is to create a holistic mental wellness campus for Cleveland, combining cutting edge treatments like ketamine infusions with health professionals specialized in providing accompanying therapy and lifestyle education. We strive to grow and adapt as the scientific body of research continues to expand and diversify for mental health treatments to lead Cleveland into the future.