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Referral Health Form

Thank you for your interest in Headlight Health. To get started, please fill out the form below.

To contact please call (866) 249-1440 or email to [email protected] with the patient’s first and last name in the subject line.

[email protected](866) 249-1440

Date of Referral

Referring Medical Group Name

Referring Provider

Contact Information for Referring Provider

Patient name*

Date of Birth*

Patient Phone*

Patient Email*

Patient’s Insurance

Policy ID

Group Number

Referring To TherapyMedication EvaluationSpravato (Esketamine) Therapy

Please check all that apply DepressionADHDBipolar DisorderAnxietyStress ManagementRelationship IssuesPTSDFamily IssuesLGBTQIA+OCDSubstance UseOther

Other/Additional Comments

Thank you for your submission. Please print or save this document for your records.

Print / Save Your Entry Start a New Referral

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988: Call or text the National Suicide Prevention Lifeline for 24/7 emotional support.
911: If you’re having a medical or mental health emergency, call 911 or go to your local ER.

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