Provider Referral Form

Providers please submit referrals directly through the form below and we will reach out to your patient within 1-2 business days. Please feel free to contact our Practice Director, Tristan Ramsey, with any questions.

Email: tramsey@galiacollaborative.com

Phone: (513)216-0068 x700

Fax: (513)216-0068

Provider Information

Referring Provider Name(Required)

Name of Practice(Required)

Email(Required)

Phone(Required)

Fax

Patient Information

Patient Name(Required)

DOB(Required)

Email(Required)

Phone(Required)

Referring to:

Ketamine-Assisted Psychotherapy (KAP)

Psychotherapy / Counseling

Psychiatry

Energy Healing

Breathwork

If there is a specific provider at Odessa that you'd like your patient to see, please let us know below.

Presenting concerns and active diagnoses.(Required)

Please upload any referral documents that may be helpful.

Max. file size: 300 MB.

Odessa is a program of Galia Collaborative, a mental health practice focused on elevating the impact of girls and women through modern mental health. For Galia's full range of mental health services, visit the website.