referrals

Submit a Client Referral

Welcome to our secure partner referral form. This page is designed for providers who want to connect a client with Zen Recovery Home for detox, residential treatment, or recovery support. Please share the details you have — our team will follow up quickly to ensure a smooth transition of care.

Zen Recovery Home - Client Referral
Zen Recovery Home – Client Referral
About This Form

This secure referral form collects only the minimum necessary client information to coordinate care. All details are private, HIPAA-protected, and handled with the highest confidentiality.

Referral Partner Information
Referring Organization / Agency
Date
/ / Calendar
First Name
Last Name
Title
Phone
Email
Client Basic Information

Please provide any client details you have available. These fields are not all required — share only what you know so we can follow up appropriately.

Client Name (PHI)
Client Phone Number (PHI)
Client Date of Birth (PHI)
/ / Calendar
Referral Needs
Primary Reason for Referral (PHI)
Insurance Coverage (PHI)
    Referral Notes / Additional Information (PHI)
    Acknowledgement
    Today