Professional Referral Form
Thanks for referring your patient to us for mental health care. We need some basic demographic, insurance, and clinical information in order to process the referral. All information submitted here is confidential and HIPAA-compliant.
Name of Referring Clinician/Clinic/Office/ER/Hospital: *
Your answer
Please note: If any of the following are true, we will unfortunately not be able to accept the referred patient into our practice, and it would be better to refer the patient elsewhere: *
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