Referral Form for Psychiatric Services
Refer your patients to us for mental health services.
Our clinicians provide both therapy and/or medication management as options for treatment. La Lune accepts most private commercial insurance plans (excluding Medicaid). Complete our HIPAA compliant form below and we will reach out to your patient within 24 hours. We are currently serving the states of Arizona, Colorado, Oregon, New Hampshire, and Washington.
Patient's Name
*
First Name
Last Name
Patient Location
*
Please Select
Arizona
Colorado
New Hampshire
Oregon
Washington
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Insurance Plan
Please note: We are not in-network with Medicaid plans. If patients are private pay, you can indicate that here.
Insurance Member ID (if applicable)
If you are referring to a specific provider at La Lune, please provide their name:
Please describe the patient's care needs, if appropriate.
Referring Practice or Provider
*
Referring Practice or Provider email
*
example@example.com
Referring Practice or Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
*
Please Select
Colleague
Client
La Lune Outreach
Insurance Directory
Social Media
Psychology Today
Professional Network
ChatGPT
Web search
Other
If other, please describe:
Provider Acknowledgement
This secure form is intended for use by licensed healthcare providers for treatment coordination.Under HIPAA [45 CFR §164.506(c)(2)], providers may disclose patient information to another provider for treatment purposes without separate patient authorization. If you are not a healthcare provider (for example, a case manager, school representative, employer, or family member), please do not include identifiable patient information unless you have obtained written patient consent.
Submit
Accepted Insurance
Should be Empty: