Patient Referral Form

Please complete the HIPAA-compliant referral form below to refer a patient to Roamers Therapy. Our intake team will review the information and contact the patient within 2 business days.

If you do not hear from us, please feel free to reach out at [email protected]. Thank you for trusting us with your referral.

Disclaimer: Roamers Therapy does not provide emergency response services. If this patient is experiencing acute risk or an immediate safety concern, please direct them to emergency services (911), the nearest hospital, or a local crisis resource prior to submitting this referral.

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Full Signature Name:

Referring Provider Information

Your Full Name *

First

Last

Credentials (LCSW, LCPC, MD, etc.)

Email *

Practice / Clinic Name:

Phone *

Referred Patient Information

Patient Full Name *

First

Last

Preferred Pronoun

Phone *

Date of Birth *

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Email *

Insurance Information (if known)

Insurance carrier, member ID, group ID, etc.

Reason for Referral

Primary concern(s) (anxiety, depression, PTSD, relationship issues, life transitions, trauma, etc.) // Is the patient seeking individual therapy, couples therapy, family Therapy? // Brief description of symptoms or presenting issue

Is there any current risk or safety concern?

Release of Information *

• By submitting this referral, the referring provider confirms that the patient has given permission for their information to be shared with Roamers Therapy for the purpose of initiating care and coordinating treatment. Roamers Therapy may contact the patient using the information provided.

Today's Date

Signature

Clear Signature

Roamers Therapy does not provide crisis or emergency response services. If this patient is experiencing acute risk or an immediate safety concern, please direct them to emergency services (911), the nearest hospital, or a local crisis resource prior to submitting this referral.

Submit Referral