Michigan - Patient Referral Form

Patient Referral Form

Use this form to refer your patient to Michigan Sleep Center (https://misleepcenter.com/) for insomnia care. Our practice focuses on CBT-I (cognitive behavioral therapy for insomnia).

This form is HIPAA-compliant. Alternatively, you may also fax referrals to (844) 333-0460. You can fax us directly, or our fax is also integrated with Athena.

We aim to reach out to all patient referrals within 1 business day of form submission.
Referring clinician information
Referring clinician name*

Your first nameYour last name
(Optional) How would you like to keep updated on your patient's progress?
We can provide updates by fax, email, or phone. We try to proactively update you on your patient's progress and will do our best to honor any requests you have about care coordination or updates. If you don't want updates, please let us know as well.
Patient information
Patient name*

Patient's first namePatient's last name
Patient contact number*
We will attempt to call your patient to schedule an appointment within 1 business day.
(Optional) Patient email
We will try emailing the patient if they don't pick up their phone.
(Optional) Patient's insomnia symptoms:

Trouble falling asleepTrouble staying asleepWaking up too early and trouble falling back asleepPoor sleep qualityOther
(Optional) Please enter any relevant diagnoses, medical history, or other notes here
Should be Empty:

Patient Referral Form