Nema Health Referral Form
This form is for healthcare providers who would like to refer a patient to Nema Health. The information collected is stored on a HIPAA-compliant platform.

After submitting this form, your patient will be contacted by Nema Health within 24-48 business hours.
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What is your name? Please provide first & last name. *
Which of the following best describes you? *
In which state(s) do you practice? *
Required
What is your organization or employer? *
What is your phone number? *
What is your email address? *
What is your fax number? *
What is the patient's name? Please provide first & last name. *
What is the patient's phone number? *
Please provide a brief reason for your referral of this patient to Nema Health. *
In your professional opinion, what are the diagnoses of this patient? Please include whether you believe the patient has PTSD.
How did you hear about Nema? *
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