Professional Referral Form
Thanks for referring your patient to us for mental health care. We need some basic demographic, insurance, and clinical information to process the referral. All information submitted here is confidential and HIPAA-compliant.
PLEASE NOTE - WE ARE CURRENTLY SCHEDULING NEW PATIENT APPOINTMENTS INTO JANUARY 2019 DUE TO HIGH DEMAND AND THE UPCOMING HOLIDAY BREAK FOR OUR STAFF. PLEASE BE PATIENT AS WE PROCESS NEW PATIENT REGISTRATIONS AND TRY TO MANAGE OUR WAITLIST. WE WILL CONTACT EVERYONE IN JANUARY (IF NOT SOONER) AS OPENINGS COME AVAILABLE.
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: *
Required
Next
Never submit passwords through Google Forms.
This form was created inside of Providers for Healthy Living, LLC. Report Abuse - Terms of Service