Professional Referral Form

Professional Referral Form
Thank you for referring a patient to us at Proven Pathways Psychotherapy. We accept private pay, Aetna, Cigna, Medical Mutual, OhioHealthy, and Devoted Health.

Please complete the confidential and HIPAA-compliant form and we will contact the client within one business day to discuss their needs.
Referring Provider Name (or organization, if no specific referring provider)
Referring Provider/Organization Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Provider/Organization Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Name

First NameLast Name
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email
example@example.com
Patient's Health Insurance Carrier, if known (e.g., Aetna, Cigna, etc.):
Reason for Referral
How would you like to be updated regarding this patient's care? We can discuss this preference with the patient and, if they consent, we can communicate the following with you as desired:

Other
Should be Empty:

Thank you for referring a patient to us at Proven Pathways Psychotherapy. We accept private pay, Aetna, Cigna, Medical Mutual, OhioHealthy, and Devoted Health.