Refer a Patient Please complete this form with as much detail as you can. Referral source: * Case manager Detox facility EAP Employer Inpatient psychiatric unit Member services directory PCP office PHP/IOP School Therapist Other Name of person completing the form * Relationship to patient Email of person completing the form * Patient contact number * (###) ### #### Patient email * Seeking evaluation for: * ADHD evaluation TMS Psychiatric services Genetic testing Medication management Other Thank you!
