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 Country (###) ### #### Patient email Contact person or legal guardian (in relation to the patient) Contact or legal guardian's number (in relation to the patient) Country (###) ### #### Primary insurance of the patient Aetna Cigna Highmark Independence Magellan Oscar Health Oxford Quest TriCare United Healthcare Cash client Other Seeking evaluation for: * ADHD evaluation TMS Psychiatric services Genetic testing Medication management Other Who should we contact to schedule initial intake? * Contact person Contact patient/legal guardian directly Thank you!
