Referral Form
Please share your practice details and information about the client you'd like to refer. This form is fully HIPAA-compliant, keeping all Protected Health Information (PHI) safe and secure. Thank you!
Referring Practice / Provider Information
Referring Practice Name
Referring Provider Name
*
First Name
Last Name
Referring Practice Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Practice Email Address
*
This allows for fast follow-up!
Referred Client Information
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Phone Number
*
Please provide contact information for us to reach the patient.
Format: (000) 000-0000.
Patient Email Address
example@example.com
Insurance Carrier
*
Please Select
Aetna
Anthem BCBS
Cigna
Department of Corrections
Medicaid
Denver Health Medical Plan
Tricare
UCHealth
United Healthcare
Self-Pay
Other / Unknown
Member ID
Interested Service
*
Please Select
Medication Management
Ketamine-Assisted Psychotherapy
Both
Reason for Referral
Additional Notes or Relevant Information
Please upload any files you would like us to have
Example: Release of Information, Medical Records, Treatment Plan, etc
File Upload
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of
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