Submit A Direct Referral

For Your Patient

Practitioner Referral

Please complete as much of the form as possible.

Please note this form is for practitioners to submit referrals for their patients. If you are a patient interested in services please

Request An Appointment.

Practitioner Information

Referring Physician Name

First

Last

Clinic Name

Phone

Referral Type

Desired Service

Please Select Please Select Family Therapy Individual Therapy Veteran Benefits Assessment Children & Adolescants Cognitive Therapy for Insomnia Parent/Child Interaction Therapy Imagery Rehearsal Therapy Integrated Behavioral Health Lucid Dreaming Therapy Grief & Bereavement Geek/Superhero Therapy

Patient Information

First

Last

Parent/Guardian

Phone Number

Can We Leave A Message? Can We Leave A Message? Yes No

DOB

Age

Insurance Information Insurance Information Tricare Cigna MHN Aetna Triwest Self Pay Use Out Of Network Benefits Other

ID Number

Group Number

Insurance Phone Number

Does the patient have a secondary insurance? Does the patient have a secondary insurance? Yes No

If "yes" is selected can we gather this information from the patient or your office? If "yes" is selected can we gather this information from the patient or your office? Yes No

Is the patient the primary member on the insurance plan? Is the patient the primary member on the insurance plan? Yes No

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Additional Notes

Name

Email Address

Message

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Office

15 Enterprise, Suite 250

Aliso Viejo, CA 92656

(949) 522-7500

Weekdays : 10am – 6pm

Weekends : Closed