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Be Very Resilient Referral Form
This form is for healthcare providers or
clinicians
who would like to refer a patient to Be Very Resilient. The information collected is stored on a HIPAA-compliant platform.
After submitting this form, Be Very Resilient will contact the referred client no more than 48 business hours.
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* Indicates required question
Email
*
Your email
What is your name? Please provide first & last name, and professional title (e.g. psychiatrist, psychologist, etc.)
*
Your answer
What is your organization or employer?
*
Your answer
What is your phone number?
*
Your answer
What is your fax number?
Your answer
What is the patient's name? Please provide first & last name.
*
Your answer
What is the phone number of the individual you are referring?
*
Your answer
Please provide a brief reason for your referral of this individual to Be Very Resilient.
*
Your answer
In your professional opinion, what are the diagnoses of the individual?
Your answer
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