Referrals

Submit a Referral

Use the form below to refer a client to Uplift Behavioral Health Services. Our team will follow up promptly to coordinate care.

Referral Form

Referrer Information

Your Name

Organization / Agency

Phone

Client Information

Client's Full Name *

Client's Phone *

Client's Email *

Client's Date of Birth *

Client's Gender *

Client's Street *

Client's City *

Client's State *

Client's Zip Code *

Language Spoken *

Relationship to Client *

Service Information

Type of Service

Client Prefers

RemoteIn-person

Is the appointment Urgent? (Same day or next day appointment)

YesNo

Urgent Care

Our triage team will review this and contact you within 2 to 4 hours during business hours.

Insurance / Plan for Payment *

Policy Number

Presenting Concern *

Please complete all required fields. By submitting this form you agree to receive communications by text message from Uplift Behavioral Health Services about your inquiry. You may opt-out by replying STOP or ask for more information by replying HELP. Message frequency varies. Message and data rates may apply. Privacy Policy

Referral Information

If you are a Service Provider, you may also submit a referral via fax to (617) 390-7008 (West Roxbury office).

Please include the following:

Basic contact information and type of service requested
Client needs and a statement about the presenting concern
Insurance or plan for payment (if known)

Uplift Behavioral Health Services

5260 Washington Street
West Roxbury, Massachusetts 02132

617-942-6040 (West Roxbury)508-313-9994 (Brockton East)508-301-3444 (Brockton South)

Have questions first?

Our bilingual team is happy to walk you through the referral process before you submit.