Refer a Patient

Refer a Patientmeemitt2024-11-02T17:02:48+00:00

Patient Information

Patient's Legal Name(Required)

First Last

Patient's Preferred Name

Patient's Date of Birth(Required)

MM slash DD slash YYYY

Patient's Gender

Male

Female

Other

Gender, if other

Patient's Email(Required)

Enter Email Confirm Email

Patient's Phone

By entering the phone number, the patient agrees to receive SMS messages from Radiant Minds if the opt-in box below is checked.

Do we have the patient's permission to text on this phone number?(Required)

Yes

Consent

The patient consents to receive SMS messages from Radiant Minds regarding appointments, updates, and promotions.

Message & data rates may apply. Reply STOP to opt-out, HELP for support. Message frequency varies. No purchase required. View our Privacy Policy and Terms of Service.

Patient's Address

Primary Insurance Provider(Required)

Insurance ID Number(Required)

Referring Provider Information

Provider Name(Required)

First Last

Provider Type(Required)

Psychiatrist/PMHNP

PCP/APRN

Therapist

Other

Provider Type, if other(Required)

Provider Email(Required)

Enter Email Confirm Email

Provider Phone

Practice name

Reason for Referral

Primary Diagnosis(Required)

Suicidal Ideation

Yes

Current Medications/Treatments

Previous Treatments (if applicable)

Reason for Esketamine (Spravato) Therapy Referral

Additional Notes/Comments

HIPAA Disclaimer:

Your privacy and confidentiality are important to us. By submitting this form, you acknowledge that the information provided will be handled in accordance with HIPAA regulations. We are committed to protecting your personal health information and ensuring it remains confidential. Please avoid sharing sensitive health details unless necessary for your inquiry.

“Hope” is the thing with feathers –
That perches in the soul –
And sings the tune without the words –
And never stops – at all –

By: Emily Dickinson

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Depression Disorders
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Phone and FAX: (978) 955-2582 | contactus@radiantmindsma.com | Radiant Minds, LLC, 21 George St Ste 203, Lowell, MA 01852-2228