Doctors, teachers, and other community service providers are able to contact us and refer clients to The Imagine Center by several convenient means. You may now send us referrals for your patients, clients, or students using the form below. 

As always, you may also send your referral by fax to (313)656-4053. 

Please complete the interactive form linked to the right, then save and attach along with the required information on the following form.

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Your Name:*

Your Email:

Patient Name:*

Patient Phone Number:*

Subject:

Message (if applicable):

Attach your completed referral form:

Acceptable file types: pdf.
Maximum file size: 1000kb.

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