Clinician Referral
Referring Clinician's Name
*
MD
NP
PA
Credentials
First Name
Last Name
Clinician's Specialty
*
Clinician's NPI
Practice Fax Number
We will fax you a completed note once the patient is seen
Format: 000-000-0000.
Patient's Name
*
First Name
Last Name
Reason for Referral
*
Post-partum depression/anxiety
Mood (Depression/Anxiety/Bipolar) disturbance
ADHD
OCD
Other
Is this an URGENT REQUEST?
*
No, standard timing (1-3 weeks) works
Yes, treat as a rush
Patient's Phone Number
*
Please enter the best contact phone number.
Format: 000-000-0000.
Patient's Insurance
*
Blue Cross/Blue Shield
Aetna
Cigna
Self-Pay
Other (Note we do not accept UMR/Optum, Medicare, Medicaid, or Tricare)
Upload most recent note, labs or imaging, if available (optional but appreciated)
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Labs of interest: CBC, CMP, fasting glucose, HbA1c, lipids, TSH. Imaging report of CT or MRI Head appreciated, if available.
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