Client Referral Form

Thank you for Referring a Client

Please complete the below information for your referral.

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Client Name*

First Last

Client Email

Client Phone*

Client Insurance Name*

Client Insurance ID #*

Client Date of Birth*

Referring Provider Name*

First Last

Provider Email

Provider Phone*

Referrral Notes*

Upload Client Insurance card and other documents

Max. file size: 100 MB.

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If you or your loved one is dealing with substance addiction, seeking help is the first step. If you are ready to get started with treatment, call our office at 1-833-762-1013

Talbot Health Services has been providing alcohol and drug prevention, education and intervention services for Northwest Ohio for past ten years. Talbot Health Services, is now taking the next step in our service history by providing Addiction treatment and Mental Health Services.

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