Healthcare Professional Referral Form

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Thank you for your referral to New Day Therapy. Please complete the form below to refer a patient to our practice. Once completed and reviewed, someone from our office will reach out to the patient within 5 to 7 business days. Please note that, at this time, most of our therapists are scheduling new patients approximately 3 to 4 months out. Our Nurse Practitioner is scheduling approximately 2 months out. Once the patient has been contacted, a fax will be sent to your office with the scheduled appointment date and time or a reason that we have declined the referral. Please see note section at the end for any additional that you would like to add. Also, feel free to fax any additional documents to our secure fax line at 304.48.3345.

Referring Provider's Name and Fax Number *

Patient's Name (Last, First) *

Patient's DOB *

YYYY

Patient's Phone Number *

Patient's Email Address *

Who are you referring the patient to? *

First Available

Russell Philpott, LPC

Christa Raitz, LPC

Michele Fling, LPC

Erin Deitzler, LPC

Kelli Nay, LPC

Janel Nuzum, MHNP

Required

Reason for Referral *

Insurance Company *

Insurance ID / Policy Number *

Policy Holder Name and DOB (if different than patient)

Patient's Current Pharmacy *

Emergency Contact Name *

Emergency Contact Number *

Additional Notes

Submit

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