REFERRALS & NEW CLIENTS

Make a Referral or Request for Services.

Looking for care for yourself, or referring a client, student, patient or family member? Share a few details and our intake team at Shaker Family Recovery will reach out to discuss services and next steps.

Insurance information helps us check your coverage before the first appointment. If you’re not sure, choose “Not sure” and we’ll help.

Please don’t include diagnoses, medical records or detailed treatment history. We’ll talk through what’s needed by phone.

If you or someone else is in crisis, call or text 988. For a medical emergency, call 911.

Fields marked required must be completed. This form is sent securely to our intake team; the website does not store it.

Who is this for?

I’m requesting services for myselfI’d like to become a client I’m referring someone elseA client, patient, student or family member

About you

First name (required) Last name (required)

Date of birth (required) Phone (required)

Email (optional) City or ZIP code (optional)

Preferred language (optional) Best time to call (optional)

Preferred location (required) Service needed (required)

Insurance Insurance type (required)

Insurance company or plan name (optional) Member ID (optional)

Policyholder name (optional, if different) Policyholder’s relationship to client (optional)

Anything else? Brief note (optional, no diagnoses or records)