By way of my signature below, I provide. Arizona is one of only 20 states that allow patients complete, unrestricted access to a physical therapist.Complete our Referral Form below or contact our clinic. Our staff will obtain a physician's signed request for an evaluation for treatment. If you would like to make a referral to Phoenix Home Care, please complete the form below. Can I fill out any New Patient Forms and bring them with me? Client Referral Form. To refer someone to us, use the form below so we can have as much information as possible. Todays date. Referral. USE THIS FORM ONLY if you are a 3rd Party entity requesting verification of an Arizona licensed PT or certified PTA.