Patient Referral-from Physician to BRR

Patient Referral Form

For Eating Disorder Evaluation and Treatment
This form is confidential and HIPAA-compliant
to safeguard your patient's protected health information.
Referring Physician *

First Name Last Name Credential (MD, DO, etc.)
Physician Email *
We don't share your information.
Physician Phone Number *

Area Code Phone Number
Physician Fax Number

Area Code Phone Number
Referral Coordinator/Case Coordinator/Physician Office Contact

First Name Last Name
Phone Number

Area Code Phone Number
Patient Information
Patient Name *

First Name Middle Name/Initial Last Name
Patient Date of Birth *

Month Day Year
Date
Gender Identiy

Male Female Transgender male Transgender female Non-Binary
Patient Pronouns

He/Him She/Her They/Their
Patient Email
example@example.com
Patient Phone Number *

Area Code Phone Number
Patient Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient Insurance Carrier (if available)
Referral Type
For which level of care is this patient being referred? *

Partial Hospitalization Program (PHP) Intensive Outpatient Program (IOP) Outpatient Psychotherapy Nutrition Counseling Please evaluate patient and make recommendation for level of care
Eating Disorder Diagnosis *

Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder Other Specified Feeding and Eating Disorder (OSFED) Avoidant/Restrictive Food Intake Disorder Please evaluate patient and make diagnosis
Additional Mental Health Diagnoses *

Major Depression Obsessive Compulsive Disorder (OCD) Generalized Anxiety Disorder (GAD) Post Traumatic Stress Disorder (PTSD) Substance Use Disorder (SUD) Bipolar Disorder
Medical Diagnoses:
Notes or Additional Information:
Enter the message as it's shown *
Should be Empty:

Patient Referral Form

Patient Information

Referral Type