Refer a client to Caladrius Therapy's DBT Program
Help us connect your client with the care they need! Use this quick referral form to share basic info about your client and their situation. We’ll follow up promptly (within 48 hours) to ensure a smooth transition and coordinated care. As it generally takes 4 - 6 weeks to complete DBT orientation and start the DBT Program, please make sure your client has adequate therapeutic support until beginning the full program.
Provider information
Provider name
*
First Name
Last Name
Provider phone number
*
Please enter a valid phone number.
Provider email address
*
example@example.com
Client information
Client name
*
First Name
Last Name
Client phone number
*
Please enter a valid phone number.
Client email address
*
example@example.com
Client date of birth
-
Month
-
Day
Year
Date
Does the client know about this referral?
*
Yes
No
What insurance does the client have?
Please Select
Blue Cross and Blue Shield of North Carolina
Aetna
Cigna (now Evernorth Behavioral Health)
UnitedHealthcare
Optum
MedCost
Humana
Tricare
Ambetter
Medicaid (NC Medicaid / NC Health Choice)
Medicare
None (self-pay/private pay)
Other
Clinical background
What is the treatment diagnosis?
*
What psychological services is the client currently receiving?
Are there any social, legal, substance use, or medical concerns?
What is your clinical justification for referring the client for DBT?
Submit
Should be Empty: