Referrals

Referral Form
Please fill out the details below to refer someone to our program.

Name *

Phone Number *

Referring Agency

By submitting this request, you confirm that you are either submitting this for yourself, or you are submitting this with the consent of said person.

* This data is required to submit the form.

© 2024 - Better Life Partners

THIS APPLICATION CONTAINS PROTECTED HEALTH INFORMATION, WHICH IS TRANSMITTED PURSUANT TO AN AUTHORIZATION OR AS PERMITTED BY LAW. THE INFORMATION HEREIN IS CONFIDENTIAL INTENDED ONLY FOR USE BY THE DESIGNATED RECIPIENT WHO/WHICH MUST MAINTAIN ITS CONFIDENTIALITY AND SECURITY. IF YOU ARE NOT THE DESIGNATED RECIPIENT, YOU ARE STRICTLY PROHIBITED FROM DISCLOSING, COPYING, DISTRIBUTING, OR TAKING ACTION IN RELIANCE ON THE CONTENTS HEREOF. IF YOU HAVE RECEIVED THIS DOCUMENT IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY AND ARRANGE FOR THE RETURN OR DESTRUCTION OF ALL ITS CONTENTS. UNAUTHORIZED REDISCLOSURE OF CONFIDENTIAL HEALTH INFORMATION IS PROHIBITED BY STATE AND FEDERAL LAW.