Referral Form

We appreciate your interest in our IOP program. We are happy to accept both provider - and self-referrals at this time. This referral form is HIPAA Compliant. Please contact our front desk at 401-500-0424 if you have any questions. Our fax number is 401-296-3995.

Referral for Intensive Outpatient Program

Date

Program Options *

General Intensive Outpatient Program

OCD & Anxiety Intensive Outpatient Program

Legal First Name

Legal Last Name

Preferred Name

Pronouns

Birth Date

Phone #

Email Address

Referral From

Provider Name

Phone #

Fax #

Email Address

At this time, our Intensive Outpatient Program (IOP) is covered by the following insurances. However, we would be happy to see if a patients insurance that is not listed below would be willing to cover the daily program fee.

Type of Insurance

Please select one of the following choices

NHPRI Commercial

NHPRI Medicaid

United Commercial

United Medicaid

Blue Cross Commercial

Cigna

Self-pay

Reason for your Referral

Please include diagnosis, reason for higher level of care, recent hospitalizations, etc.

Reason for your Referral

Is there a significant/primary substance abuse concern?

Yes

Please upload any notes and/or records below.

Thank you!

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