Provider Referral Form

Providers please submit referrals directly through the form below and we will reach out to your patient within 1-2 business days. Please feel free to contact our Practice Director, Tristan Ramsey, with any questions.

Email: tramsey@galiacollaborative.com

Phone: (513)216-0068 x700

Fax: (513)216-0068

Provider Information
Referring Provider Name*
Name of Practice*
Email*
Phone:*
Fax
Patient Information
Patient Name*
DOB*
Email*
Phone*
Referring to:
- Psychotherapy / Counseling
- Psychiatry
- Nutrition
- Parent Coaching
If there is a specific provider at Galia that you'd like your patient to see, please let us know below.
Presenting concerns and active diagnoses.*
Please upload any referral documents that may be helpful.
Max. file size: 300 MB.
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Provider Referral Form

Provider Information

Patient Information

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