Provider Referral Form
Please use this secure form to make a referral to Premier Behavioral Health Services. You may also send this information via fax 440-266-0257.
Date
*
-
Month
-
Day
Year
Date
Provider Name
*
Practice/Clinic Name
*
Provider Email
*
example@example.com
Provider/Clinic Phone Number
*
Format: (000) 000-0000.
PATIENT CONTACT INFORMATION
Patient Name
*
First Name
Last Name
Patient Age
*
If the patient is a minor, please include parent or guardian contact information in the additional clinical information field.
Patient/Parent Phone Number
*
Format: (000) 000-0000.
Reason For Referral
Individual Therapy
Intensive Outpatient Program
Medication Management (provided as part of integrated care)
Unsure (include further information in box below)
Additional Clinical Information
Submit
Should be Empty: