Practitioner Referral Form

Practitioner Referral Form
Charlotte's Premiere Provider of Neurofeedback, Biofeedback, and Neuromodulation
Clinical Director: Melanie Berry, MS, BCB-F, BCN, QEEG-D, FAIS Email: melanie.berry@cbfclinic.com

Clinical Team:
- Aubrey Berry, MA, BCB-P, QEEG-D
- Meleah Dement, MS, LMHC, LPC, BCN, CHP
- Maddie Waters, MS
- Grace Gallagher, MS
- Rachel Oruko, MA, QP, ATR-BC, LCMHC
- Sandy Smith, Certified NeuroDevelopmental Specialist
- Riley Dorman, MA in progress
Office Manager: Korinne Dunn Email: Korinne@cbfclinic.com

Website: www.carolinasbiofeedback.com

Phone Number: 888.317.5605

Mailing Address: 9835 Pineville-Matthews Rd. #567, Pineville, NC 28134

Physical Address South Charlotte : 115 College Street, Suite 201, Pineville, NC 28134

Physical Address North Charlotte : 511 Jetton Street, Davidson, NC 28036

Physical Address S. CLT Brain Studio : 7400 Carmel Executive Park Suite 130, Charlotte, NC 28226
Patient/Client Name:*
Patient/Client Birthdate:*

MonthDayYear
Date
Gender:
Patient/Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient/Client Address:*
Client Phone Number*

Area CodePhone Number
Client Email*
example@example.com
If patient is a minor; please list contact name for above number and relationship to patient:
Diagnos(es):*
Diagnosis Code(s):*
Reason for Referral:*
Make selection
Choose office location preference
Contact Instructions*

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 a call or an email from you.They are already a client of CBFC but requested I provide a referral.
Is there anything else you think we should know about your referral?
Name of Referring Practitioner:*
NPI#:
Email*
example@example.com
Office/Practice Name:
Practitioner Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Address:*
Practitioner or Office Phone Number:*
Mobile Number

Area CodePhone Number
Fax Number:
Referring Provider Signature:*

Clear
Date:

MonthDayYear
Date
Would you like regular contact about this client?

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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