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Professional Referrals
Synergy Psych seeks to create exceptional patient experiences, and that begins by determining if we are a good fit for the person you are referring. Please share more with us and know that we will follow up to help.
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* Indicates required question
Email
*
Your email
What is your name?
*
Your answer
Phone number
*
Your answer
Which best describes your role?
*
Outpatient therapist
Residential treatment program
Hospital
Primary Care Physician practice
Psychiatry practice
Gynecology practice
Professional Monitoring Organization
Church
Other:
What is the name of person you wish to refer?
If you do not have their consent to share their identity and/or protected health information (and are required by your profession to have one), you may elect to provide just their first name or skip this question.
Your answer
Which best describes this referral:
*
This person requested that I reach out on their behalf and wants to be contacted by Synergy to schedule an appointment.
This person requested that I reach out. Please reply only to me with information about Synergy, availability, etc.
This person does not know that I have reached out to Synergy, but I would like more information.
Other:
If you are recommending that we reach out to this person, please provide contact information for us to reach them (i.e., cell number, email address) and their preferred method of communication (voice, text, email).
*
Your answer
How long have you known this person?
Your answer
What symptoms have you concerned? (Check all that apply)
*
Anxiety or panic
Depression or other mood disorders
Substance use
Insomnia
Obsessive compulsive symptoms
ADD/ADHD
Trauma
Other impulse control issues
Other:
Required
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