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 *
Provider Email *
Provider Fax # *
Provider phone number *
Name of patient being referred *
Date of Birth of patient being referred *
Name of parents/guardians if patient is a minor *
Have you provided the patient my card or contact information? *
Would the patient like me to contact them about setting up services? *
Patient or parent/guardian phone number *
Patient or parent/guardian email address *
What information would you like to receive in return if services are established with this patient? What would benefit their collaborative treatment plan? *
Do you already have a signed Release of Information on file for us to communicate? *
Never submit passwords through Google Forms.
This form was created inside of Psychological Health Services, LLC: Jessica Snyder, LCP & Associates. Report Abuse