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Family & Friends Referrals 

Secure Referral Form

Please do not include sensitive health information in this form. After completion, The Anxiety Treatment Center of West Michigan will be in contact with the referred person within 24 hours.

Referer Information
Referring Persons Name
Referring Person or Email Address
Referral Information

Note: If the referral is a minor, please include guardian information only 

Referrals Age Required
Referrals First Name Only!
Referrals Email Address
Referrals Phone Number 

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The Anxiety Treatment Center of West Michigan, PLLC

Email: atc@anxietykalamazoo.com

Phone: 269-359-1873

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