Client Referral-from Therapist/Dietitian to BRR

Client Referral Form

For Eating Disorder Evaluation and Treatment
This form is confidential and HIPAA-compliant
to safeguard your client's protected health information.
Referring Professional *

First Name Last Name Credential (PsyD, LMFT,RD, etc.)
Referring Professional's Email *
We don't share your information.
Referrer's Phone Number *

Area Code Phone Number
Referrer's Fax Number

Area Code Phone Number
Referral Coordinator/Case Coordinator/Physician Office Contact

First Name Last Name
Phone Number

Area Code Phone Number
Client Information
Client Name *

First Name Middle Name/Initial Last Name
Client Date of Birth *

Month Day Year
Date
Gender Identiy

Male Female Transgender male Transgender female Non-Binary
Client Pronouns

He/Him She/Her They/Their
Client Email
example@example.com
Client Phone Number *

Area Code Phone Number
Client Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Client Insurance Carrier (if available)
Referral Type
For which level of care is this client being referred? *

Partial Hospitalization Program (PHP) Intensive Outpatient Program (IOP) Outpatient Psychotherapy Nutrition Counseling Please evaluate patient and make recommendation for level of care
Eating Disorder Diagnosis *

Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder Other Specified Feeding and Eating Disorder (OSFED) Avoidant/Restrictive Food Intake Disorder Please evaluate patient and make diagnosis
Additional Mental Health Diagnoses *

Major Depression Obsessive Compulsive Disorder (OCD) Generalized Anxiety Disorder (GAD) Post Traumatic Stress Disorder (PTSD) Substance Use Disorder (SUD) Bipolar Disorder
Medical Diagnoses:
Notes or Additional Information:
Enter the message as it's shown *
Should be Empty:

Client Referral Form

Client Information

Referral Type