For Clinicians

Patient Referral Form

Thank you for referring someone you care about to FirePit Health. Whether you’re a family member, friend, or healthcare provider, we’re here to offer compassionate care and support. Please complete the form below to help us begin the referral process.

Referral Information

Relationship to Patient:

Contact Information (Phone/Email):

Healthcare Provider Information (If applicable)

Type of Practice/Organization:

Provider’s Name:

Provider’s Contact Information (Phone/Email):

Any Special Considerations or Recommendations from the Provider:

Patient Information

Patient’s Date of Birth:

Patient’s Address:

Phone Number:

Email Address:

Preferred Method of Contact:

Referral Details

Substance(s) Involved:OpioidsAlcoholPrescription MedicationsOther (Please specify)

Additional Information:

Consent to Receive Communications

By submitting this form, you agree to receive text messages and emails from FirePit Health. You acknowledge that you have read and understand our Privacy Policy, Terms of Service, and SMS Policy. You can opt out of communications at any time by following the instructions provided in the messages.

I agree to receive text messages and emails, and I have read the Privacy Policy, Terms of Service, and SMS Policy.

Consent to Contact

By submitting this form, I acknowledge that I have received the patient’s consent to share this referral with FirePit Health and that the patient is aware of the referral process.

I confirm that I have received consent.

Submit Your Referral

Once submitted, our team will review the referral and contact the patient to discuss their treatment options. Thank you for helping us connect individuals with the care they need.

Thank you! Your submission has been received!

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For Clinicians

Patient Referral Form

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