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Refer a Patient to Team Recovery

Team Recovery works with healthcare providers, hospitals, treatment professionals, and community partners to connect individuals with the appropriate level of behavioral health care. Complete the referral form below to provide our team with the information we need to begin coordinating care.

If you would prefer to speak with our team directly about a referral, call (419) 314-4909.

Patient Referral Form

Referring Provider Information

Referring Provider(Required)

Organization(Required)

Role

Phone Number(Required)

Email Address

Patient Information

Patient Name(Required)

Date of Birth

Mobile Number(Required)

City

Postal Code

Insurance Provider

Referral Information

Reason for Referral(Required)

Requested Level of Care

Patient’s Current Location

Desired Admission or Discharge Date, if Applicable

Additional Information(Required)

Supporting Documents

If you have supporting documentation related to this referral, you may upload it below. This may include assessments, discharge paperwork, clinical records, or other information that may help our team coordinate care.

Upload Supporting Documents

Drop files here or

Max. file size: 50 MB.

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Refer a Patient to Team Recovery

Patient Referral Form

Patient Referral Form

Referring Provider Information

Patient Information

Referral Information

Supporting Documents

Consent / Acknowledgment

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