Refer a Patient

If you feel your patient could benefit from Telehealth Outpatient Mental Health Treatment, please complete the information below.

Required Field (*)

Client Information

Is the Client Aware of and Agreeable to this Referral?

Is the Referral Urgent?

Client's Full Name*

Client's Date of Birth

Client's State

Client's Phone Number*

Client's Email*

Best Way to Contact Client*

May We Leave a Message?

Referrer Information

Referring Agency*

Referrer Full Name*

Referrer Email*

Reason for Referral*

Primary Insurance Type of Client

Primary Insurance Carrier of Client

Member ID of Client

Group ID of Client

Policy Holder Name of Client

By Submitting this form, I confirm that I have discussed Youme healthcare's services with the individual listed above and have their permission for Youme Healthcare to reach out to them, via electronic channels, and I understand that Youme Healthcare is a telehealth therapy provider.

If you are in a life threatening situation, don’t use this site. Call 911 or use these resources to get immediate help.

Corporate:
Youme Healthcare
6655 Santa Barbara Rd.
Ste 8574
Elkridge, MD 21075

866-YOUMEHC (866-968-6342)
intake@youmehealthcare.com

Privacy Overview

This website uses cookies to improve your experience while you navigate through the website. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. We also use third-party cookies that help us analyze and understand how you use this website. These cookies will be stored in your browser only with your consent. You also have the option to opt-out of these cookies. But opting out of some of these cookies may affect your browsing experience.

Necessary

Always Enabled

Necessary cookies are absolutely essential for the website to function properly. These cookies ensure basic functionalities and security features of the website, anonymously.

Cookie	Duration	Description
cookielawinfo-checbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.

Functional

Performance

Analytics

Others