Patient Referral (Linktree) Complete the form below to submit your referral Professional's contact informationFirst Name *Last Name *Phone *Email Address *Company *Professional's title *Relationship to the Patient *Select *How did you hear about us?EmailFacebookInstagramLinkedInOpen HouseNetworking eventsColleagueMediaOtherPatient's contact informationFirst Name *Last Name *Phone *Email Address *Date of Birth *Does the patient have Insurance? *YesNoField GroupSelectInsurance NameAetnaAnthem Blue Cross CommercialAnthem Blue Cross MedicalBlue Shield CaliforniaCarelon - CommercialCignaComPsychHeritage/LakesideLYRAMagellan CommercialMedicareMHN CommercialMultiPlanOptumTriwestTricareOtherIf you didn't find your insurance - type itPatient's Insurance ID numberDo you know if your patient has secondary insurance?YesNoSelect2nd Insurance NameAetnaAnthem Blue Cross CommercialAnthem Blue Cross MedicalBlue Shield CaliforniaCarelon - CommercialCignaComPsychHeritage/LakesideLYRAMagellan CommercialMedicareMHN CommercialMultiPlanOptumTriwestTricareOtherIf you didn't find your insurance - type itPatient's Secondary Insurance ID numberService you are requesting *IOP for Substance UseIOP for Mental HealthPHP for Substance UsePHP for Mental HealthNot Sure(Need Evaluation)PsychiatryPsychotherapyPatient's Location *CaliforniaFloridaIndicate patient's availability *MorningAfternoonEveningProfession *Type of Professional *FacilityClinicianService Type *ResidentialIOP (Intensive Outpatient)PHP (Partial Hospitalization Program)Practice Type *Group TherapyGroup PracticeSolo PractitionerSpecialty *State *LocationAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingFacility/Service Type *HospitalResidentialIOP/PHPGroup PracticeSolo PracticeLevels of Care OfferedPlease check all that apply within each categoryOutpatient Services *PsychotherapyPsychiatryPrimary Mental HealthCo-Occurring Substance Use/Mental HealthIntensive Outpatient Services (IOP) *PsychotherapyPsychiatryPrimary Mental HealthCo-Occurring Substance Use/Mental HealthAge Groups Served *TeensYoung AdultsAdultsIs there anything else you'd like to share about your patient?Send Message
