Behavioral health referral form

By submitting this form, you confirm that the patient has agreed to allow AbleTo to evaluate their coverage and reach out with available behavioral health care options.

*Required Field

AbleTo is a URAC telehealth accredited national provider of behavioral health services and does not share or sell patient information. View our Terms of Use and Privacy Policy.

If you have questions about AbleTo services, email us at referrals@ableto.com or call 833-422-5386 (TTY: 711),
9am – 8pm ET, Monday – Friday

Before you continue

Inform the patient an AbleTo behavioral health team member will be reaching out through email or phone to discuss services they are eligible for.

You must complete this action to submit the form

Yes, the patient understands an AbleTo behavioral health team member will be reaching out to discuss services. *

Insurance Provider *
Subscriber/Member ID *

Reason for Referral *

First Name *
Last Name *

Date of Birth *

State *

Zip Code *

Email *

Phone *
CDO Market *