Better mental health starts here

★ Covered by Medicare

Total Life connects older adults with licensed therapists who understand their unique needs. We provide secure, compassionate care entirely online or by phone.

This form takes about 3 minutes. We'll ask for a few details about the person you are referring and your contact information.

I AM REFERRING AS A...

medical_services

Healthcare professional

Doctor, social worker, discharge planner

group

Family, friend, or caregiver

Referring a loved one for care

Not referring someone? → Book therapy for yourself

security HIPAA COMPLIANT SECURE PORTAL

Patient information

Please fill in the details of the person you're referring. All fields are required unless marked optional.

PATIENT DETAILS

First name *

Please enter a valid first name

Last name *

Please enter a valid last name

Date of birth *

/ /

Please enter a valid date of birth (MM/DD/YYYY)

Zip code *

Please enter a valid zip code (5 digits or ZIP+4, e.g. 12345 or 12345-6789)

Phone number *

Please enter a valid 10-digit phone number

Email address *

Please enter a valid email address

I don't know their email

Gender (Optional)

Insurance details

OPTIONAL

Adding insurance information helps us verify coverage quickly.

Primary insurance provider

Please select a primary insurance provider

Member ID

Please enter the primary member ID

Secondary insurance (if applicable)

Please select a secondary insurance provider

Please fill out primary insurance first

Secondary member ID (if applicable)

Please enter the secondary member ID

verified_user HIPAA COMPLIANT SECURE PORTAL