Here at Healizm, we strive to provide stellar care. We accept commercial insurance panels including Empire BCBS, Aetna, UHC-Optum, CIGNA, Humana and Medicare. In efforts to confirm we are a good fit for our patients, we kindly request for you to fill out the form below to confirm if a telepsychiatry practice is an appropriate platform for the patient or not. We truly appreciate your assistance with this. Of note, given we are predominately a telepsychiatry practice, we currently do not prescribe controlled substances. Our sincerest apologies for this inconvenience. ADHD screenings are still available along with noncontrolled substance alternative treatments.

Referral Form

Referral Provider

Date / Time

Patient First Name

Patient Last Name

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone Number

Insurance Patient Uses

Reason for Visit (i.e., mood disorder, depression, anxiety, trauma, Bipolar disorder, OCD, eating disorder):

Has the patient been treated for mental health before?

Are they on any Psychiatric medications, if so, which ones?

Are they on any non-psychiatric medications if so, which ones?

Medical Conditions the patient has?

Previous suicidal attempts? If so, how long ago?

Previous psychiatric inpatient hospitalizations? If so, how long ago?

History of violence?