Online Referral Form

Please complete all fields; click the submit button when complete.  The form will be forwarded to the Intake Department at Lowenstein House.   Please note that referrals to Lowenstein House must be made by a licensed practitioner or recommended by a licensed practitioner at your facility.  For self-referrals, talk to your doctor or other licensed person providing services to you to recommend your referral to Lowenstein House.  Please note that fields with a red asterisk (*) are required.  The submit button will not activate until all required fields are completed.

Questions?  Call Lowenstein House's Intake Manager at (901) 274-5486.‚Äč