Outpatient Referral Form

We are happy to accept referrals and questions.

Cedar Rapids: (319) 286-4545 or therapyreferral@tanagerplace.org

Coralville: (319) 286-4520 or CoralvilleBHC@tanagerplace.org

If you prefer, a PDF version of this form is available for download.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Providing an email address, if available, helps us connect you to needed services as efficiently as possible.
  • Date Format: MM slash DD slash YYYY
  • Recommended Services

  • Please include information about current symptoms, behaviors, functioning and trauma
  • Insurance & Documentation

    Please attach copy of insurance card and ABA documentation, if applicable, in upload section below. Insurance verification required before appointment. Tanager Place is unable to accept Medicare insurance at this time. Private pay rates are available for insurances out of network. While insurance information is not required as part of this form, providing it now will expedite the path to treatment.
  • Date Format: MM slash DD slash YYYY
  • Drop files here or
    Accepted file types: jpg, pdf, png, gif.
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