Provider Referral for Therapy Services
If you are a health-care provider and would like to refer a patient for therapy services with Jessica Snyder, LCP at Psychological Health Services (PHS), please complete the form below. This information will be submitted securely to Jessica for follow-up.
Provider Name and Credentials *
Your answer
Provider Email *
Your answer
Provider Fax # *
Your answer
Provider phone number *
Your answer
Name of patient being referred *
Your answer
Date of Birth of patient being referred *
MM
/
DD
/
YYYY
Have you provided the patient my card or contact information? *
Would the patient like me to contact them about setting up services? *
Patient phone number *
Your answer
Patient email address *
Your answer
What information would you like to receive in return if services are established with this patient? What would benefit their collaborative treatment plan? *
Required
Do you already have a signed Release of Information on file for us to communicate? *
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