Submit Referral to Portland Sleep Therapy

This form is HIPPA-compliant

Thank you for your referral.

This form may be used by healthcare professionals, behavioral health providers, recovery professionals, or prospective clients seeking sleep-focused services.

Please complete the form below. A response will typically be provided within 1–2 business days.

CLIENT INFORMATION

First name

Last name

Email address

If preferred contact method

Phone number

If preferred contact method

REFERRING PROVIDER

First name

Last name

Email address

Organization

Notes

Your information will be encrypted.