Refer A Patient To Fort

This form is HIPAA compliant

Refer a patient to potentially receive behavioral health services with Fort Health.

We will reach out to your referral within 1 business day and inform you when we've been in contact with them. Please provide your direct contact information below so that we can keep you updated. For any questions, please email refer@FortHealth.com. Please note at this time Fort only accepts referrals for patients residing in New York, Pennsylvania, and New Jersey.

Patient Information

Child First Name*

Child Last Name*

State*

Child Date of Birth*

Child Sex Assigned at Birth*

This patient or their legal guardian has consented to receiving email and text messages from Fort Health*

Parent or Guardian Information

Relation to Patient*

First Name*

Last Name*

Phone Number*

Email*

Referring Physician

Name of Practice, Office, or Clinic*

Referring Pediatrician*

Contact Person First Name*

Contact Person Last Name*

Contact Person Role*

Contact Person Email*

Office Phone Number*

Office Fax Number*

Referral Notes

If you are experiencing a mental health emergency or medical emergency, please call “911” or 1-800-273-TALK (8255) to reach a crisis center or text 741741 to reach the Crisis Text Line.

* This patient or their legal guardian, as may be required, has agreed to receive communications, including emails and text messages, from Fort Health regarding this referral and accessing health care, treatment, and services, and has provided their e-mail address and mobile phone number for the purpose of receiving these communications. The patient/guardian has acknowledged the risks that may be associated with receiving health information via unsecured email or text messaging.