REFERRAL FORM

REFERRAL FORM
Carolinas Biofeedback Clinic

Charlotte's Premiere Provider of Neurofeedback, Biofeedback, and Neuromodulation
Clinical Director: Melanie Berry, MS, BCB-F, BCN, QEEG-D, FAIS

Clinical Team
- Aubrey Berry, MA, BCB, QEEG-D
- Meleah Dement, LMHC, LPC, BCN, CHP
- Maddie Waters, MS
- Grace Gallagher, MS
Office Manager: Lisa Berryhill
Mailing Address: 9835 Pineville-Matthews Rd. #567, Pineville, NC 28134
South Charlotte Physical Location: 115 College Street, Suite 201, Pineville, NC 28134
South Charlotte Brain Studio Location: 7400 Carmel Executive Park Suite 130, Charlotte, NC 28226
North Charlotte Physical Location: 511 Jetton Street, Davidson, NC 28036
Website: www.carolinasbiofeedback.com Email: melanie.berry@cbfclinic.com
Automated assistant: via text at 704-275-9294
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I directed my referral to www.carolinasbiofeedback.com to book a free phone consult.My referral will call your office at 888-317-5605.Please contact my referral, they are expecting an email from you.They are already a client of CBFC but requested I provide a referral.
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I would like to know when they scheduleI would like a snapshot status on their progress monthlyI would like to schedule a phone call with Melanie Berry to discuss the results of any quantitative assessments my referral does (QEEG, Cognitive Performance Tests, etc.)Just mail me a copy of any quantitative assessmentsI will contact you when I have questions about my referral's progress or protocolsNo, I prefer to hear only from the clientOther
Describe what kind of contact you would like us to have regarding your referral
PLEASE FAX ANY PERTINENT MEDICAL RECORDS TO 888-317-5605 or UPLOAD.
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Thank you!

We appreciate your confidence and will take very good care of your referral.
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REFERRAL FORM

Carolinas Biofeedback Clinic