Refer a Patient

Together we can eliminate suicide deaths and enable better access to mental health care.

I'm Looking for Myself

If you would like to connect with Vita for your personal mental health needs, register online now for therapy and one of our care team will be in touch shortly.

Alternatively you can reach out to our care team at the number below to discuss any questions you may have.

GET STARTED

430 New Park Ave Ste 102
West Hartford, CT 06110

Our Care Team

Phone: +1 (844) 866-8336
Fax: +1 (888) 892-4723

Refer your patient using the form below

Welcome to Vita Health!

Please use this form to make a referral to Vita Health. After you submit this form, a member of our care coordination team will work with the patient to schedule an appointment. Referring providers will be notified of appointment details.
Vita email
Your information
Your name*

First NameLast Name
Your office name*
E.g. provider office name, insurance name, etc
Your office address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your office phone number*
Your office fax number
Notes
Please provide any pertinent history about the patient
Patient information
Patient legal name*

First NameLast Name
Patient preferred name
Patient pronouns

She/her/hersHe/him/hisThey/them/theirsOther
Patient phone number*
Patient email*
Patient address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient insurance provider
Is insurance subscriber different than the patient?

YesNo
Insurance subscriber name*

First NameLast Name
Insurance subscriber date of birth*

MonthDayYear
Patient date of birth*

MonthDayYear
Is the patient under 18 years of age?*

YesNo
Parent / legal guardian name*

First NameLast Name
Parent / legal guardian phone number*
Parent / legal guardian email*
Should be Empty:

Refer a Patient

I'm Looking for Myself ​

Our Care Team

Refer your patient using the form below

Your information

Patient information

I'm Looking for Myself