Community Behavioral Health Professional Referral Form
Please answer every question in this form so our intake team can expedite your referral to allow for the patient's appointment to be made as soon as possible.

IDENTIFYING INFORMATION
Full Legal Name (As It Appears on Patient's ID) *
Patient's Date of Birth *
MM
/
DD
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YYYY
Patient's Social Security Number, if available
###-##-####
Best Contact Number for Patient *
(###)-###-####
Address (Street Number, Street Name, City, State, and Zip Code)
Patient's Email Address
Race
Clear selection
Gender
Clear selection
REFERRING PHYSICIAN OR OTHER PROVIDER CONTACT INFORMATION
Physician/Other Provider/Agency Name *
Physician/Other Provider/Agency Phone Number *
(###)-###-####
Physician/Other Provider/Agency Email Address
(###)-###-####
Physician/Other Provider/Agency Fax
INSURANCE INFORMATION
Please enter if available. If you do not have this information, please skip this section. We will contact the patient to obtain the information and verify insurance prior to scheduling their first appointment.
Insurance Carrier Name
Insurance Carrier Plan
Insurance Member ID Number
Group Number
Claims Phone Number
Claims Address (including city, state, and zip)
Policy Holder Name
Policy Holder Date of Birth
MM
/
DD
/
YYYY
Policy Holder Social Security Number
Secondary Insurance Carrier Name:
If none state N/A
Secondary Insurance Carrier Plan:
Secondary Insurance Member ID Number:
Secondary Group Number:
Secondary Insurance Claims Phone Number:
Secondary Insurance Claims Address:
Will the patient require a sliding scale payment option?
Clear selection
REASON FOR REFERRAL
Please explain the reason for the referral *
Clinic Location (select more than one if you are interested in referring for services available at different locations) *
Required
Specialty Programs (Please indicate if you are interested in referring one or more of the following specialty services) *
Required
Note About TMS and Spravato
Please be aware patients who have failed at least 2 antidepressant trials and meet criteria for treatment resistant major depressive disorder are eligible for these services.

Patients may not be prescribed or actively take benzodiazepines, stimulants, MAOIs, or take any recreational drugs in order to receive these services. If their urine drug screen is found positive for any of these substances, treatment will be immediately terminated for the patient's safety.

Patients must not have any metal implants in order to receive TMS.
Patient's primary medical diagnoses *
Please list any of the patient's seasonal, food, or medication allergies *
Current Medications *
Thank you for completing this form. For TMS, Esketamine (Spravato), Substance Abuse, and Psychiatric Rehabilitation Program (PRP) Services, please complete the follow up questions in the following sections. If you are not referring to any of those services, please skip to the end of the questionnaire to submit your referral.
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