Professional Referral Form

Professional Referral Form
Thank you for referring a client to us at Proven Pathways Psychotherapy. We accept private pay, Aetna, Cigna, Medical Mutual, Humana, 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.
Referring Provider/Organization Fax Number
Please enter a valid phone number.
Client Name

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

Full diagnostic evaluationDiagnosis and treatment planSummary of completed treatmentNo updates neededOther
Should be Empty:

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