Get Help for Your Patient

If you’re looking to refer your patients or clients to Alabama Clinical Schools, please fill out the secure, confidential form below and a member from our Admissions department will reach out to you in a timely manner. If you have further questions, give us a call at 205-836-9923. Any required information or hard/electronic copies of your referral information can be faxed to 205-836-9483 or emailed to [email protected].

Patient Name*
First Last
Patient Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Insurance Carrier*
Referred By*
Referral Contact Phone Number*
Diagnosis/Symptoms to be treated/Reason for referring*
Custodian*
Race*
Requested Program*
Email
This field is for validation purposes and should be left unchanged.

We’re Always Here to Help

Licensed mental health professionals are available 24/7 to schedule a no-cost, mental health assessments by calling 205-836-9923. For questions about our programs, you can also use our online contact form. In the case of a medical emergency or crisis, please dial 911 or go to the nearest emergency room.