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 NameLast NameCredential (MD, DO, etc.)
Physician Email*
We don't share your information.
Physician Phone Number*

Area CodePhone Number
Physician Fax Number

Area CodePhone Number
Referral Coordinator/Case Coordinator/Physician Office Contact

First NameLast Name
Phone Number

Area CodePhone Number
Patient Information
Patient Name*

First NameMiddle Name/InitialLast Name
Patient Date of Birth*

MonthDayYear
Date
Gender Identiy

MaleFemaleTransgender maleTransgender femaleNon-BinaryOther
Patient Pronouns

He/HimShe/HerThey/TheirOther
Patient Email
example@example.com
Patient Phone Number*

Area CodePhone Number
Patient Address

Street Address

Street Address Line 2

CityState / 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 PsychotherapyNutrition CounselingPlease evaluate patient and make recommendation for level of careOther
Eating Disorder Diagnosis*

Anorexia NervosaBulimia NervosaBinge Eating DisorderOther Specified Feeding and Eating Disorder (OSFED)Avoidant/Restrictive Food Intake DisorderPlease evaluate patient and make diagnosisOther
Additional Mental Health Diagnoses*

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

Patient Referral Form

Patient Information

Referral Type