Referring Professionals Network | Banyan Treatment Center

Referral Form

Fill out this form to be included in our referral source network. Tell us a little bit about your organization so we can make sure to add you to our list.

Personal Information

First Name
Last Name
Email
Company

Address

Street
City
State/Province
Zip
Website

Company Information

Outreach Territory:
How did you hear about us?:
Type of Business:
How many locations?:
When did you open?:
Are you state licensed?:
Which accreditations do you hold?:
Do you provide housing?:
Primary Focus:
Approach:
Levels of care provided?:
Select all services provided:
Age group treated:
Insurances you are in network with:
Insurances you are out of network with:
Company Description:


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Don't surrender your life to addiction, take control and get your life back today. Our drug and alcohol addiction treatment centers have helped thousands of people empower themselves to take back control of their lives. It's time for your roots to grow in new soil!