Nizhoni Health Systems

Referral Intake Form

Referrals can be made 24 hours a day, 7 days a week. Most often, services can be in place within a few hours. To make a referral, use the easy, secure online form below, download the PDF form, or call (800) 915-3211 and ask to speak with one of our Intake Representatives. Outside of business hours, simply ask the receptionist to connect you with the Clinician on-call.

*Required fields
REFERRAL SOURCE
CLIENT DEMOGRAPHIC INFORMATION
REFERRAL INFORMATION
CLINICAL INFORMATION