• (817) 251-7995
  • 1100 Kimball Ave unit 110, Southlake, TX 76092

Avalyn Wellness
and Ketamine

Send Us A Referral

Refer a patient securely and we’ll take it from there.

Use the form below to refer a patient to Avalyn Wellness & Ketamine. Once received, our team will review the referral and contact the patient (or your office) to coordinate next steps.

Send Us a Referral

Referring Provider / Office

Name(Required)
Best Method to Contact You

Patient Information

Patient Name(Required)
Preferred Contact Method
Patient Address
Reason for Referral(Required)

Consent

Consent(Required)

What Happens Next?

  • We review the referral (typically within 1 business day)

  • We reach out to confirm details and eligibility

  • We schedule an intake or provide next-step guidance