Referral Form

Referred By: *

Referral Contact Number

Referral Contact Email

Please note:

At this time we are not accepting patients who have been hospitalized more than once in the past 18 months and hospitalization needs to be less than 2 weeks long. *Does not apply to out-patient addiction recovery program.
We may ask for patients to be present at the time of hospital discharge scheduling to provide consent and ensure a comprehensive intake process for effective scheduling.
We do not offer detox services and cannot wean patients off of medications.
Please make sure contact numbers are up to date and patients are aware we will be calling.

In order to ensure that we have the proper resources to meet your patient's needs CLICK HERE for a full list of criteria items to consider when referring a patient for services at MindPath Care Centers.

Patient Demographics

First/Last Name: *

DOB: *

Address: *

Address:

Home Phone: *

Cell Phone:

Reason for Referral

Details: *

Insurance Information

Insurance Company: *

Subscriber Name:

Subscriber DOB:

Insurance ID:

Group #:

Insurance MH/SA Phone #

2nd Insurance Company:

2nd Insurance ID:

2nd Group #:

2nd Insurance MH/SA Phone #

Who needs to be contacted to schedule an appointment? *

Please call the patient directly.

Please call the referring clinic directly.

Patient Demographics

Reason for Referral

Insurance Information

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