Make a Referral

Provider Request for Services

At Ease USA’s mission is to eradicate Post Traumatic Stress. Over the last decade, we have become well aware of the many challenges our military members and their families have endured. If you or a loved one has been impacted by PTS, Suicidal ideations and self-harm, Moral Injury or Trauma, At Ease USA’s team of experts are here to help.

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Do you believe this client is struggling with PTSD, suicidal ideations and self-harm, moral injury or trauma? If yes, please proceed with intake questionnaire.

REFERRAL SOURCE INFORMATION

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CLIENT INFORMATION

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Relationship to Military:*

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Insurance Information

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