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Referral Form
Providers:
Please complete our
HIPAA-compliant
form below to make a referral to INSPIRD Nutrition & Mental Health Counseling.
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* Indicates required question
Client Information
Please complete the following information about the client you are referring.
Client's First Name
*
Your answer
Client's Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Please enter a valid phone number.
Your answer
Email
*
example@example.com
Your answer
What services is this referral for?
*
Nutrition Counseling and Medical Nutrition Therapy with a Registered Dietitian
Mental Health Counseling with a mental health therapist
Both Nutrition Therapy and Mental Health Therapy Services
Required
Diagnosis Code
*
List the diagnosis code(s) for the condition/reason that they would be receiving our service. If there is not yet a diagnosis code on their chart, please describe the main reason/concern for the referral.
Your answer
Client's Health Insurance Provider
Please enter the client's health insurance provider that they may use for coverage of services (if applicable)
Your answer
Referring Provider Information
Please complete the following information about the referring provider.
Referring Provider's Name & Credentials
*
Your answer
Practice or Facility Name
*
Your answer
Referring Provider NPI
Your answer
Phone Number of Referring Provider
*
Please enter a valid phone number and extension if applicable
Your answer
Email of Referring Provider
*
example@example.com
Your answer
Fax Number of Referring Provider
*
Please enter a valid fax number.
Your answer
If additional information or communication is needed, what is your preferred method of contact?
*
Phone
Fax
Email
Other:
Required
Is there any other information you think would be helpful for us to know about this client?
Your answer
Client Files:
Please fax a referral order for nutrition therapy and/or mental health therapy (including diagnosis code) to (618) 989 0403
How did you hear about INSPIRD Nutrition & Mental Health Counseling?
Another healthcare provider or practice
You have previously shared a mutual client with us
A patient or client
Google
Facebook
Instagram
LinkedIn
Health Insurance Company Website/Provider List
Other:
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