Patient Referral

New Patient Referral
To refer a patient to Confidant Health, please fill out this secure HIPAA compliant form. We’ll use the patient's information to reach out to them, and your information to share progress updates.

You can also send us an email at referral@confidanthealth.com or call us at 203-747-8696.

If you would like to fax us a referral, our fax number is 203-747-8696.
Patient Information
Patient Name*

First NameLast Name
State*
Mobile Number*
Please include the area code
Email Address
Referrer Information
Referring Contact Name*
Referring Contact Email
Medical Group or Organization (if any)*
Additional Notes
By submitting this form, I understand that Confidant Health is an outpatient telemedicine-based substance use disorder and mental health provider.
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New Patient Referral