External Provider Referral Form

External Provider Referral Form

(Return with clinical notes via fax (802) 258-3788 or email Outpatient@brattlebororetreat.org)
Please choose only one primary service requested:*

Outpatient Therapy (individual, group)Outpatient Psychiatry (Therapy may be deemed required)Transcranial Magnetic Stimulation (TMS)Partial Hospitalization Program/Intensive Outpatient Program (PHP/IOP)Healthcare Professionals and First Responders (HPFR)
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number*
Please enter a valid phone number.
Does the patient have access to a computer or tablet with a webcam and in-home internet connection?*

YesNo
Does the patient have access to a private space during treatment appointments?*

YesNo
Primary Insurance Provider*
Insurance Policy #*
Previous/Current Diagnosis*
Reason for Referral*
Referred By*
Practice Name*
Provider Phone Number*
Please enter a valid phone number.
Submission date*

MonthDayYear
Date
File Upload

Cancelof
Upon receipt of completed referral and clinical notes, the next steps are as follows:

Patient responsibility:
- Complete and return the program packet (assistance is available if requested)
- Attach insurance card images
Brattleboro Retreat steps:
- Financial eligibility will be reviewed within 48 business hours.
- Clinical review to determine program eligibility.
- Patient will be contacted with next steps.
Should be Empty: