Referral – Brio Counseling Center

Physician Referral Form

Thank you for referring your patient to Brio Counseling Center. Please complete this form and submit. The patient must sign a Release of Information (ROI) allowing you to share information with Brio Counseling Center and allowing us to contact the patient before sending this referral.

Patient Information

Full Name

Date of Birth

Phone Number

Address

City / State / ZIP

Referring Physician Information

Physician Name

Practice / Clinic

Phone Number

Referring Details

Reason for Referral

Relevant Medical / Mental Health History

Current Medications

Urgency

Additional Notes

By submitting this referral, the referring physician confirms that the patient has signed a Release of Information permitting the sharing of relevant health information with Brio Counseling Center and the client has agreed to be contacted by Brio Counseling Center.