Client Referral-from Therapist/Dietitian to BRR

Client Referral Form

For Eating Disorder Evaluation and Treatment
This form is confidential and HIPAA-compliant
to safeguard your client's protected health information.
Referring Professional

First NameLast NameCredential (PsyD, LMFT,RD, etc.)
Referring Professional's Email
We don't share your information.
Referrer's Phone Number

Area CodePhone Number
Referrer's Fax Number

Area CodePhone Number
Referral Coordinator/Case Coordinator/Physician Office Contact

First NameLast Name
Phone Number

Area CodePhone Number
Client Information
Client Name

First NameMiddle Name/InitialLast Name
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender Identiy

Other
Client Pronouns

Other
Client Email
example@example.com
Client Phone Number

Area CodePhone Number
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Insurance Carrier (if available)
Referral Type
For which level of care is this client being referred?

Other
Eating Disorder Diagnosis

Other
Additional Mental Health Diagnoses

Other
Medical Diagnoses:
Notes or Additional Information:
Enter the message as it's shown
Should be Empty:

Client Referral Form