Psychiatry Referral Form [For Providers]

Refer your patients to us for psychiatric care.

We’re accepting new clients in California, Connecticut, Florida, Illinois, Maryland, Massachusetts, Michigan, New Jersey, New York, Nevada, Oregon, Pennsylvania, Texas and Washington!

We accept most major commercial insurance plans [excluding Medicaid] and private pay.

Lavender Psychiatry isn’t for everyone; learn more here about what we treat & prescribe.

Complete our HIPAA compliant referral form, and we’ll gladly reach out to your patient; or give them our website and they can complete our online self-triage process.

Patient's Name

First Name

Last Name

Patient's Location

Patient's Email

Patient's Mobile Phone

(###)

###

####

Patient's Date of Birth

YYYY

Patient's Insurance (Optional)

Only in-network plans are listed in the drop-down below. If you don't see your patient's insurance, we're out of network, and they'll have to pay out of pocket. We can assist with out of network reimbursement submissions.

Member ID

If you'd like your patient to see a specific NP at Lavender, please provide the NP's name

Reason for Referral*

Please elaborate on patient care needs, if appropriate.

Referring Practice / Provider Name

Referring Practice / Provider Email

Referring Practice / Provider Phone

(###)

###

####

How did you hear about us?

If other, please describe

We accept the following insurance:

Learn more about our prescribing practices.

Responsible Prescribing

Psychiatry Referral Form [For Providers]

Refer your patients to us for psychiatric care.

We accept the following insurance:

Learn more about our prescribing practices.

If you’re having a medical or mental health emergency:

People flourish here.