Please provide your professional information if you are accepting new referrals.

Why? We believe SO strongly in the research showing that collaborative care leads to better treatment outcomes, that we hired a licensed therapist at Remedy- not to do therapy with Remedy patients, but to match Remedy patients with a specific talk therapist (or IOP/PHP program) that is a fit for their needs and desires.

We look forward to collaborating with you!

Please feel out as many details as possible so that we may refer optimal patients to you.

(Fields with an *asterisk are required fields)

First Name *

Last Name *

Email *

Phone

Website

Profession *

License Type

Collaboration interest- I am interested in: (Multi-select)

Group or Individual Professional Provider *

Group

Individual

Contact's Role of Professionals (Multi-select)

Speciality

Accepts Insurance? *

Insurance(s) Accepted (Multi-select)

Treatment Services (Multi-select)

Virtual/ In-person/ Both

Therapy Modalities (Multi-select)

Diagnostic Specialties (Anxiety, OCD, etc.) (Multi-select)

Languages Spoken Beyond English (Multi-select)

Notes

Receive Messages

By checking this box, I consent to receive marketing and educational messages from Remedy, including the free, 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. (Required for us to contact you)