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Would you like a confirmation from our administrative team that your referral was received and we reached out to your patient? Please note, an email is required above for this follow up
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Referring Clinician

Referring Clinician's Phone Number

Referring Clinician's Practice

Patient's Name

Include parent's name if the patient is a child

Patient's Email

Patient's Phone Number

Reason for Referral

IBS

IBD

Functional Abdominal Pain

Functional Nausea

Other GI

Other Health Disorder

General Mental Health

Optional: Additional Information regarding reason for referral

To send additional clinical information, you can do so by fax (703-661-9463) , by email (admin@gipsychology.com), or by providing information below.

If the patient provides consent, would you like auto reporting (treatment plan and termination note) on this patient?

Please enter email or fax number you would like this sent to.

Would you like to receive a monthly update on the patients you refer who do not engage in or decline treatment via fax? If yes, please provide a fax number below.

By checking this box, I am confirming that I have notified the patient that I am submitting this referral to GI Psychology. They understand someone will be in touch to share more about the treatments and how to engage in services.
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I have notified the patient

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