BGTS Referral Form
Are you a Provider looking to make a referral on behalf of a Patient? Please complete this form to initiate the process. A member of our Team will reach out to the Patient directly.

We are honored you have chosen our team to deliver exceptional Speech and Occupational Therapy Services. We are grateful to each of our referring hospital and provider partners for entrusting us with your patient’s care.

Please fax formal referrals and related documents to: (855) 717-0136

Brain Gains Therapy Solutions, LLC
P: (754) 216-8839, call or text
F: (855) 717-0136
Support@BrainGainsTherapy.com
BrainGainsTherapy.com

Speech Language Pathology
Occupational Therapy

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Email *
Patient’s First and Last name *
Patient DOB *
Patient STATE (CO, FL, WA) *
Parent name/s (if Patient is under 18 years old)
Patient or Parent phone number (if Patient is under 18 years old) *
Patient or Parent Email
Insurance/s name (list primary and secondary)
Referring Physician Name and NPI
Referring Practice Name *
Referring Practice Phone Number *
Referring Practice Fax Number *
Services you are referring for:  *
Required
Please briefly share the nature and goal of the referral. *
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