Refer A Patient | Edify Behavioral Health Services

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Call Us: 877-762-5469

Name of Person Being Referred*

Gender

Male

Female

Date of Birth*

Month

Day

Year

Ethnicity

Hispanic/Latino

Non-Hispanic/Latino

Race

Black/African American

White

Hispanic

Native Hawaiian or Pacific Islander

Native American

Middle Eastern

Current Address

Zip Code*

Phone number where they can be reached*

Insurance Payor

Insurance Number (Optional)

Parent's Name (if child)

Additional phone number

Name of Referral Source*

Relationship or Agency*

Email of Referral Source*

Phone Number of Referral Source*

Reason for Referral*

Comments

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Toll Free: 1-877-762-5429

Fax: 1-832-218-0204

2000 S. Dairy Ashford Suite 575

Houston, Texas 77077

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