For referring practitioners

Submit a Referral

Photograph or upload the completed referral form. Please make sure the entire page is visible and the writing is readable.

Your referral will be transmitted securely to the Institute for review.

Need a blank form first? Download it here →

Online referral submission

Referral submission is temporarily unavailable

Our secure online referral tool isn't accepting submissions right now. To refer a patient, please call us directly.

Call (972) 836-7080

Referral pages

Add the completed form

Up to five photos, or one PDF.

JPEG, PNG, compatible HEIC/HEIF, or PDF. Large phone photos are optimized automatically.

Referring practitioner

Your contact information

We only ask for what we need to identify the referral source and follow up if something is unreadable.

Referring practitioner’s name

Practice name

Phone

Email

I confirm that I am authorized to submit this information for referral and treatment purposes. I have read and agree to the Terms of Use and acknowledge the Privacy Policy.

Do not close this page until you see a confirmation number.

Submission complete

Referral received

Thank you. The Institute has received your referral. Please keep confirmation — for your records.

Submitting this referral does not schedule an appointment. Families should call (972) 836-7080 to schedule.

Submit a Referral

Referral submission is temporarily unavailable

Add the completed form

Selected pages

Your contact information

Referral received