Refer a Patient

By submitting this form, you are representing that the referring clinician has obtained the appropriate consent of the below named patient to share their information with GBHP and to have GBHP contact the patient to evaluate clinical treatment options. You can also download this form and fax it to (407) 878-6663

Patient Information
Patient Name*
Date of Birth: (mm/dd/yyyy)*
MM slash DD slash YYYY
SS #
Primary Phone*
Alternate Phone
Gender
Address*
Street Address Address Line 2 City State ZIP Code
Insurance Name/Plan*
Member Services ID
Carrier’s Direct Phone # for Behavioral Health:
ID #
Group #
Effective Date
MM slash DD slash YYYY
Policy Holder Name*
Date of Birth: (mm/dd/yyyy)
MM slash DD slash YYYY
Relation to Patient
Reason for Admission
Primary Diagnoses*
Mental Health Medications
Discharge Date
MM slash DD slash YYYY
Past or current issues with substance use? (If yes, which substance(s))
Specific Requests?
GBHP intake staff will try to honor a patient request; however, requests may not always be feasible due to availability, location, etc.
Referral Information
Referring Practice/Physician*
Department
Phone #*
Email Address
Fax Number
Primary Care Physician
Appointment Requests
Please check all that apply
Appointment Requests*
- Evaluate and Treat
- Medication Management
- Assessment for Intensive Outpatient Program
- Occupational Therapy
- Individual Therapy
- Nutritional Counseling
- Psychological Testing
For additional questions, please call the Georgia Behavioral Health Professionals at 678-820-7868. Thank you for referring.
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Patient Information

Referral Information

Appointment Requests