Lead Record Type

Step 1 of 7

What is your relationship to the patient?

You have selected your relationship to the patient as Referring Provider. Please complete the additional required form fields below so that you can proceed to the next step.

Referring Provider's Name

Referring Provider's Phone

Referring Provider's Email

Referring Provider's Company

Step 2 of 7

What is the patient’s name?

Enter Date of Birth

Embrace U’s therapy programs are designed for adolescents aged 10 to 18, and require a minimum of 10 hours of treatment per week.

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Step 4 of 7

Participants and their families gain the support they need through group experiences and structured individual and family therapy. Most participants experience significant symptom reduction after four weeks of treatment.

Please select at least one option in order to proceed to the next step.

What treatment options are you considering?

Intensive Outpatient Therapy
Partial Hospitalization Program
1-on-1 Counseling
Group Therapy
Medication Management
Rehab for Drug or Alcohol Dependence
Inpatient Treatment
Not Sure - I want help deciding the best next steps

Patient's presenting symptoms?

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Step 5 of 7

What insurance do you have?

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Step 6 of 7

This step is optional. Please check the box if you would like to provide your insurance information at this time.

Insured Name

Insured Date of Birth

Employer Insurance provider

Member ID or Subscriber ID

Group Number

Phone number on the back of the card

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Step 7 of 7

Parent's Name

Parent's Phone

Parent's Email

Location

I agree to receive text messages and phone calls from Embrace U regarding my inquiry.

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(833) 733-4325