Referral Form

Fill out this form to be included in our referral source network. Tell us a little bit about your organization so we can make sure to add you to our list.

Personal Information

First Name
Last Name



Company Information

Outreach Territory:
How did you hear about us?:
Type of Business:
How many locations?:
When did you open?:
Are you state licensed?:
Which accreditations do you hold?:
Do you provide housing?:
Primary Focus:
Levels of care provided?:
Select all services provided:
Age group treated:
Insurances you are in network with:
Insurances you are out of network with:
Company Description:

Personal healing begins with a

simple choice.

Get others the help they need at Banyan

If you are struggling with drug or alcohol addiction the battle does not have to be yours to fight alone. Banyan Treatment Center is here to help you grow through your recovery process. By filling out the form below you can take the first step towards a fulfilling life clean and sober. After the form is completed you will be contacted by one of our highly experienced admissions counselors, most who are in recovery themselves. They can further assist you with any questions you may have.

For immediate help please call:

(815) 865-3282