Referral (or collaboration) Form

Please enter the patient's information using this HIPAA encrypted secure form. Please view Remedy Psychiatry's Privacy Policy for information about how information is collected and used.

Once you submit this form, our team will reach out to the patient and to you, within 72 business hours to confirm receipt and discuss next steps.

If you have any additional questions, you can always email us at [email protected] and/or call us at 747-212-3876, option 3

(which is the dedicated line for collaborative care).

We look forward to working with you!

Patient Information

Patient First Name *

Patient Last Name *

Patient Phone *

Patient Email *

Referring Provider Information

Provider First Name *

Provider Last Name *

Speciality *

Provider Phone *

Provider Email *

NPI Number *

Clinical Information you'd like to convey (optional):

Patient (If a new referral) Has Given Permission To Be Contacted *

Yes

Receive Messages

By checking this box, I consent to receive marketing and educational messages from Remedy, including the monthly evidence-based Remedy educational newsletter for mental health professionals. I understand that I can opt out and unsubscribe at anytime. (Optional)

By checking this box, I consent to receive messages related to services I have requested, including requests to collaborate in patient care. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.