Contact Us At
BasePoint Academy

Discover What Teenage Mental Health Conditions We Treat at BasePoint Academy

7:00 am to 7:00 pm
7 Days a week

provider Referral form

Please use this form to provide information on clients you are referring to BasePoint. Our goal is to make this process simple for you.
 

  • Your Information

  • Patient Information

  • MM slash DD slash YYYY
  • Parent / Guardian Contact Information

  • Who should BasePoint Reach Out To?

  • This field is for validation purposes and should be left unchanged.

By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging, and get more help by sending HELP. –  Privacy Policy