If you would like to make a payment on an outstanding balance, please complete the secure form below.
To make a referral, please complete the items below and click “Submit” to send this confidential form to an Assessment and Referral clinician.
You can also fax it to 1-800-217-6218
This form is monitored during regular business hours only.
For immediate assistance, please call our Assessment and Referral line directly at 916-830-2223.