Referral Form

Bodhi Wellness Provider Referral Form

Thank you for referring your patient to Bodhi Wellness. Please complete the secure form below. Our team will review the referral and contact the patient to assist with scheduling.

Date

Provider Name, Practice Name, Specialty, Phone, Fax, Email

Patient Full Name, Date of Birth, Phone Number, Email, Preferred Contact Method, Insurance Provider

Reason for Referral

Psychiatric evaluation

Medication management

Psychotherapy

Hormone Replacement Therapy

Weight Loss Consultation

Brief reason for referral, Current medications, Relevant diagnoses, Relevant medical history, Safety concerns

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Add file

Please upload a file

Would you like Bodhi Wellness to provide care coordination updates?

Yes

I confirm that the patient has been informed of this referral and has provided appropriate authorization for Bodhi Wellness to receive relevant clinical information and coordinate care with the referring provider, as applicable.

By submitting this form, I understand that Bodhi Wellness will review the referral and contact the patient regarding scheduling.

By submitting this referral, the referring provider confirms that the patient has been informed of the referral to Bodhi Wellness and, where required, has provided appropriate authorization for the disclosure of relevant protected health information (PHI) for purposes of referral, treatment, and care coordination. Information submitted through this secure referral form will be handled in accordance with applicable privacy and security requirements, including HIPAA, as applicable. I confirm that I am authorized to submit this referral and that the disclosure of the patient's information is permitted or appropriately authorized for the purposes described above.

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