External Referring Providers Form

External Referring Providers Form

Book an appointment for your patient with Clarity Clinic or contact a member of our clinical team to discuss your patient's case.
Full Name*

PrefixFirst NameLast NameSuffix
What is your email address?*
example@example.com
Which organization are you referring from?*
Which age group does the patient you are referring belong to?*

Child or Adolescent (3-17)Adults (18+)
Which service line are you interested in referring your patient to?*

TherapyPsychiatryTranscranial Magnetic Stimulation (TMS)Partial Hospitalization (PHP) & Intensive Outpatient (IOP) Programs

External Referral - Therapy

Complete the below form to refer your patient to Clarity Clinic's therapy services.
OPTION 1:

My patient is currently in an appointment with me and I would like to walk them through scheduling a therapy appointment with Clarity Clinic. To do so, please use the booking link below:

THERAPY BOOKING LINK
OPTION 2:

I would like one of your clinicians to contact me for additional information and/or assistance with referring my patient to Clarity Clinic's therapy services.

External Referral - Psychiatry

Complete the below form to refer your patient to Clarity Clinic's psychiatry services.
OPTION 1:

My patient is currently in an appointment with me and I would like to walk them through scheduling a psychiatry appointment with Clarity Clinic. To do so, please use the booking link below:

PSYCHIATRY BOOKING LINK
OPTION 2:

I would like one of your clinicians to contact me for additional information and/or assistance with referring my patient to Clarity Clinic's psychiatry services.

External Referral - Transcranial Magnetic Stimulation (TMS)
OPTION 1:

My patient is currently in an appointment with me and I would like to refer them for a TMS appointment at Clarity Clinic. To do so, please complete the below form with them:
Preferred TMS Location:

Chicago Loop: 333 N Michigan Ave, Suite 1400, ChicagoArlington Heights: 2101 S Arlington Heights Rd, Suite #116, Arlington Heights
Patient Name:

First NameLast Name
Patient Phone Number:
Please enter a valid phone number.
Patient Email:
example@example.com
Patient Date of Birth:

MonthDayYear
Date of Birth
OPTION 2:

I would like one of your clinicians to contact me for additional information and/or assistance with referring my patient to Clarity Clinic's TMS services.

External Referral - PHP & IOP Programs

Complete the below form to refer your patient to Clarity Clinic's PHP & IOP programs.
OPTION 1:

My patient is currently in an appointment with me and I would like to walk them through scheduling a PHP/IOP consultation with Clarity Clinic. To do so, please use our PHP/IOP consultation link below:

SCHEDULE A PHP/IOP CONSULTATION
OPTION 2:

I would like one of your clinicians to contact me for additional information and/or assistance with referring my patient to Clarity Clinic's PHP or IOP programs.
Should be Empty:

External Referral - Therapy