Refer A Patient Securely refer your patients to Southwest Agape Wellness, PLLC for therapy and psychiatric services FacebookThis field is for validation purposes and should be left unchanged.Who is making the referral?(Required)ProviderHealth Plan RepresentativeCare ManagerPhone(Required)Email(Required) Practice NameIf not applicable, leave blankAbout The PatientLegal Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Patient or Legal Guardian Email(Required) Patient or Legal Guardian Phone Number(Required)What state does the patient live in?(Required)Insurance ProviderPrimary Health Insurance CarrierExample: BCBS, UnitedHealthCare, Medicare, Optum, Cigna, AetnaPrimary Member IDSecondary Insurance CarrierIf applicableSecondary Member IDTertiary Insurance CarrierIf applicableTertiary Member IDType of Care:(Required)TherapyPsychiatric Medication ManagementBothReason for Visit(Required)Tell us more about what the patient is experiencing. Examples: Anxiety, PTSD, substance use disorder, trouble sleeping, etc.
