Refer a Client

Submit a Referral

Complete the form below and our team will follow up within 1–2 business days.

Website

Your Information (Referrer)

Full Name *Please enter your name.

Organization *Please enter your organization.

Email *Please enter a valid email address.

Phone *Please enter a phone number.

Your RoleSelect your rolePhysicianNurse / Nurse PractitionerCase ManagerSocial WorkerDischarge PlannerCommunity Health WorkerOther

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Client Information

First Name *Please enter the client's first name.

Last Name *Please enter the client's last name.

Date of Birth

Client Phone

InsuranceSelect insurance typeMassHealthMedicareDual Eligible (Medicare + MassHealth)Commercial InsuranceUninsuredOther

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Services Needed

Services Requested *Select a serviceCare CoordinationCommunity Health Worker SupportInsurance NavigationHousing & Social ServicesHealth Education & OutreachResource NavigationMultiple ServicesPlease select a service.

Urgency LevelRoutineUrgent (within 48 hours)Emergency (same day)

Reason for Referral / Additional Notes

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I confirm that the client has been informed of this referral and has given verbal or written consent to share their information with Mantra Health Alliance for care coordination purposes. *

I acknowledge that this referral contains protected health information (PHI) and is being submitted in compliance with HIPAA regulations. *

Submit Referral