Referral Form

This referral form is transmitted and stored through a secure, HIPAA-compliant system.

All information shared here is encrypted and accessible only to authorized staff at MindLift Alliance.

Our intake team will reach out to the referred client or guardian within one business day to ensure timely support and coordination of care.

Referrer's Full Name

Referrer's Organization/School/Clinic/Doctor office

Referrer's Phone Number

Referrer's Email Address

Client (Referred Person) Name

Best time to contact the referred person?

By checking this box, I consent to receive non-marketing text messages from MindLift Alliance about our services. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from MindLift Alliance at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.