Referral Form

Please only complete this form if you are a provider/educator/etc. and not a parent/legal guardian of a potential patient you are looking to refer.

Your name (provider completing this form) *

First

Last

Your email address

Never used for spam. Collected to provide you an e-mail confirmation message that your referral was received and to reach out if we have any additional questions about your referral.

Your phone number

Never used for spam. Collected to reach out if we have any additional questions about your referral.

Your relationship to the patient you are referring *

I am the provider
Office staff on behalf of a provider
Other

Please indicate if you would like to be contacted in regards to your referral: *

No, please do not contact me
Yes, please contact me to discuss this referral further

Referred patient's name *

First

Last

Referred patient's email address (or parent's email if patient is a child): *

Referred patient's phone # (or parent's phone # if patient is a child): *

[IF PATIENT IS A CHILD ONLY] Parent/Guardian's First and Last Name:

First

Last

I am referring the patient for:

Provider Preference

Referred patient's insurance information (if known):

(This information is used to prepare our response to the potential patient regarding in-network or out-of-network coverage and does not influence scheduling or provider availability.)

Message *

I have read and agree *

By checking this box, you understand that although the information you provide in this contact form may be considered privileged and confidential, sending a message via this form does not establish a doctor-patient relationship. Given the limitations of the communication format, this is not considered a HIPAA-compliant messaging service. By completing this form, you have obtained the necessary permission/consent from your patient and/or parent/guardian to refer them to our office for services. If this is a medical emergency, please contact 911 immediately.