Referral Form

Make A Referral

Name of Client*

Date of Birth*

SSN# (Optional)

Gender: Male or Female*

County*

Medicaid (MMIS Number)*

Email*

Phone Number we can leave a message at*

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Next Steps in the Process

Addiction & Mental Health Counseling
Telehealth Counseling
Mental Illness Services
Individual Care

1. We will review your form within 24 hours.

2. We will call you to arrange your treatment options.

3. Once options are agreed, we will email you the client portal link to get started.

4. We will send you the required forms and information.

5. We will assist you on your journey to healing and recovery.

WellSprings Recovery Center

Submit your name, phone number and email address so a Member of our Care Team may contact you for a confidential conversation about you or someone you love with a substance use disorder.

Name*

Email*

Phone

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Recovering the whole person inside of you!

Healing through counseling, support and hard work.

Contact WellSprings Recovery Center

275 Graham Road, Suite #2, Cuyahoga Fallls, Ohio 44223, United States

Phone: 234-529-4891 Fax: 234-529-4896 Email: bwell@wellspringsrecovery.com

FAQ
Join Our Team

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