Provider Referral Form

Provider Referral Form

Garden City Therapy, PLLC

www.GardenCityTherapy.com

This form is intended for healthcare providers and professional referrers only.
Provider or Entity Type
Provider Name
Entity Name
Your Email
example@example.com
Your Phone Number
Client Name
Client DOB

MonthDayYear
Date
Client Email
example@example.com
Client Phone Number
Insurance Carrier / Plan Name
Clients with Medicaid must have Managed Care plan such Fidelis Medicaid, Healthfirst Medicaid or UHC/Optum Community Plan Medicaid
Insurance ID
Visit Reason or Symptoms:

Other
Client outreach
Provider Outreach
Additional Notes: Below you may include therapist preferences, scheduling availability, or any general coordination details that may be helpful. Please do not include detailed clinical information or sensitive personal health information in this field.

0/150
By submitting this form you understand that:
This information is sent to our HIPAA-compliant email. Typical response time is within the same business day, and generally no longer than 48 business hours. Thank you.
www.GardenCityTherapy.com
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