Referrals – insightful

630 Hillcrest Road, Suite 400/ Lilburn | Georgia 30047

Info@Insightfultransformations.com | 404.883.0724

Provider Referral

If you are a health care provider and you would like to refer one of your patients for mental health services, please complete the form below and I will contact the patient to discuss options.

Please let the patient know that you are making the referral before completing this form.

Patient Full Name

Patient Second Name

Patient Phone Number

Patient Email

Patient Diagnosis
Please only list primary diagnosis or those relevant to mental health care.

Reason For Referral

Does the patient know I will be calling them?

Yes No

How will the patient pay for mental health services? Please check with your patients about insurance; I field many calls form patients who do not have an insurance plan I can bill and cannot afford the cost of therapy without insurance. Referring them to the right provider right away increases the likelihood they will follow through with therapy.

The patient has insurance (Medicare, PeachState, Ambetter, CareSource, BCBS, Aenta, Cigna, and TriCare). The patient will use their Out-of-Network benefits. The patient can pay for services without using their health insurance. Other

Referring Provider or Clinic Name

Referring Provider Phone Number*

Is there anything else you think I should know?

630 Hillcrest Road, Suite 400/ Lilburn | Georgia 30047

Info@Insightfultransformations.com | 404.883.0724

Provider Referral

Please let the patient know that you are making the referral before completing this form.

630 Hillcrest Road, Suite 400/ Lilburn | Georgia 30047

Info@Insightfultransformations.com | 404.883.0724

Contact today

Address: 630 Hillcrest Road, Suite 400/ Lilburn, Georgia 30047

Phone: 404.883.0724

Fax: 855.574.0815

Email: Info@Insightfultransformations.com