Refer a Client

Send us a referral — securely.

This form routes directly to our intake command center. A team member responds within one business day.

Encrypted end-to-end

Submissions are stored in an access-controlled system aligned with HIPAA safeguards.

Response within 1 business day

You'll hear from a real coordinator — not an autoresponder.

For professionals & families

CCS, physicians, educators, case managers, family members — all welcome.

Section 1 · Referring party

About you

Full name *Email *PhoneOrganization / AgencyYour roleRelationship to client

Section 2 · Client information

About the person being referred

Client first name *Client last name *Date of birthClient emailClient phoneAddressGuardian / Advocate nameGuardian contact

Section 3 · Services & funding

What's needed

Services requested (check all that apply)

Insurance / funding sourceUrgency *

Reason for referral *

Consent to contact. I confirm that I have the appropriate consent to share this information with Relentless Alliance, and I authorize the team to contact the referring party and (where applicable) the client / guardian to coordinate intake.

Encrypted in transit. Stored in a private, access-controlled system used only to coordinate care.