Request a Referral

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Referral requests are fulfilled in 5-10 business days. If this is an urgent request, please let us know by including that information in the Notes box at the bottom of the form.

ATSA does not license, certify, or endorse individuals or organizations. All ATSA members have met the requirements for ATSA membership. To view ATSA’s membership requirements, click here.


Referral Request:

 

How should we deliver the referral?

One delivery option must be completed for us to send the referral.

If you would prefer that we mail the referral, please use the Notes box below to include your mailing address.

 

Location for treatment referral?

 

Referral Type:

select all that apply

 

Population Served:

select all that apply

 

Secondary Language (Spanish, etc.):

 

Physiological Assessment:

 

Notes:

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