Healthcare Providers

Refer your clients to therapy

After receiving your referral, a Fox Health care coordinator will contact the client or caregiver to coordinate the initial evaluation.

Your Information

First Name *

Last Name *

Email Address *

Phone *

Fax (optional)

Organization Name *

Client Details

Please provide information about the individual seeking services.

First Name *

Middle Name (optional)

Last Name *

Date of Birth *

State *

Client Phone (optional)

Client Email (optional)

Referral Details

Please let us know how best to serve this client. If you can provide insurance information we will perform an eligibility verification prior to reaching out.

Referral Needs *(select all that apply)

Speech Therapy

Occupational Therapy

Feeding Therapy

Other

Upload Forms / Assessments (optional)

☁Browse FilesDrag and drop files here

Face sheet, referral forms, insurance card, clinical notes, etc.

Reason for Referral (optional)

Referring Provider (if different from above)