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
Full diagnostic evaluationDiagnosis and treatment planSummary of completed treatmentNo updates neededOther
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.