For Healthcare Professionals

Provider Referral Form

Use this form to refer a patient or client to Family Behavioral Connections, LLC. We accept referrals from physicians, mental health professionals, hospitals, schools, and community agencies. Our team will follow up within two business days.

Medical ProfessionalsMental Health ProvidersHospitals & Inpatient FacilitiesSchools & Agencies

Referring Provider Information

Provider Name *

Provider Type *

Organization / Practice Name

NPI Number

Provider Phone *

Provider Fax

Provider Email *

Patient / Client Information

First Name *

Last Name *

Date of Birth *

Client Phone

Client Email

Insurance / Payor

Client Address

Referral Details

Requested Service *

Urgency Level *

Primary Diagnosis / ICD-10 Code

Secondary Diagnosis / ICD-10 Code

Release of Information on File?

Current Psychiatric Medications

Reason for Referral *

Previous Mental Health Treatment History

Safety Considerations *

Additional Notes / Special Considerations

Important Notice

By submitting this form, you confirm that you have obtained or will obtain appropriate authorization from the patient/client to share their information with Family Behavioral Connections, LLC. This form does not guarantee acceptance of the referral. Our clinical team will review all referrals and contact you within two business days. For urgent mental health crises, please call 988 (Suicide & Crisis Lifeline) or direct the patient to the nearest emergency room.