Provider Information
Provider Name
*
First Name
Last Name
Provider Title
MD, LMFT, Therapist, PCP, etc.
Provider Email
*
example@example.com
Provider Phone Number
Patient Information
Please discuss this referral with your patient and obtain consent before providing their information. This referral form is HIPAA-compliant. All information shared will be kept strictly confidential and used only for the purpose of coordinating patient care in accordance with HIPAA privacy and security standards.
Patient Name
First Name
Last Name
Patient Email
example@example.com
Patient Phone Number
Indicate the service(s) for which you are referring your patient:
Ketamine Assisted Psychotherapy (KAP)
Clinical Trials
Psychedelic Integration
Psychotherapy
Other
Reason for Referral/Additional Comments:
Submit
Should be Empty: