Referral Form

Referrer's Relationship to Patient*

"Other"—What is your relationship to the patient?

Referring Person's First Name*

Referring Person's Last Name*

Provider Name*

PrefixFirst NameLast Name

Organization/Practice*

"Other"—What is your Organization/Practice Name?

Organization Location

Email*

example@example.com

Phone Number

Please enter a valid phone number.

I agree to receive follow-up messages by email.*

I agree to receive follow-up messages by text (SMS).**

Individual's First Name*

Individual's Last Name*

Insurance Type/Payment Method (if known)

Insurance Carrier (if known)

Individual's Phone*

Please enter a valid phone number.

Individual's Email

example@example.com

City*

State*

State (All)

Requested Workit Services (select all that apply)

Opioid UseAlcohol Use

Workit Health is currently accepting new members and reaching out to referrals in the following states: Arizona, Florida, Illinois, Michigan, Montana, New Jersey, New Mexico, Ohio, Texas, and Washington.

Upload a completed Release of Information form (Note: form must be fully legible.)

Organization / Practice zzz

Full Name

Combined First Name

Combined Last Name

Combined Relationship

Combined Organization

By submitting, I agree to receive marketing messages by email and text (SMS). Messaging frequency varies. Message and data rates may apply. I can opt out anytime by replying STOP to an SMS or unsubscribing from emails. I can reply HELP to an SMS to receive support. View our Privacy Policy, Terms of Service, and Consent to SMS and Email.

SMS Agree

*Messaging frequency varies. I can unsubscribe at any time.

**Messaging frequency varies. Message and data rates may apply. I can opt out at any time by replying STOP. I can reply HELP to receive support. If I do not consent to receive SMS, and Workit Health is unable to reach me by email, I understand that they will not be able to contact me by text.

View our Privacy Policy, Terms of Service, and Consent to SMS and Email.

Input Patient Info Below