Referral Form

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

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 *

Patient 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.

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.