Community Provider Referral Form

This Referral Form is for community providers who are seeking clinicians and/or prescribers for a specific client. The content of this form will be shared with our membership of over 780 providers on our private membership platform and you will be emailed directly by available providers who fit your request.

Please submit information exactly as you would like it shared. Please be cognizant of PHI and HIPAA compliance.

**If you a member of the PPC please post your referral directly to the platform in the Referral Forum**

Please provide your full name, credentials, location, and email

Please provide the condensed version of the referral (as in a subject of an email):Age, gender of client, location, insurance, brief problem statement, therapist characteristics

Referral Description

Additional Notes (optional)

Please check all that apply:

Thank you for submitting a referral to the PPC Membership Community. Please email us at info@privatepracticecolloquium.com with any questions or feedback on how we can better support you.