Referral Form

To refer a patient to us, please complete the form below and our team will follow up with the caregiver directly. We look forward to caring for your patients.



Referring Provider's Group *


Nearest Cortica Center

We’re committed to your privacy. Cortica uses the information you provide to us through this secure and HIPAA-compliant form to contact you about our relevant services. You may unsubscribe from these communications at any time. For more information, check out our privacy policy.

If you are a parent or caregiver interested in starting services at Cortica for your child, please click the "Get Started" button at the top right of this page.

Prefer to fax us instead of filling out this form? You can also refer a patient to Cortica by faxing Cortica’s enrollment team at (888) 417-4189.

"It’s an unbelievable dream that J. has blossomed in this way. We didn’t know he knew so much. Now we can communicate. He’s so proud that he can demonstrate what he knows."

-Parents of a Young Adult With Autism Spectrum Disorder