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.