Refer a patient

For providers and provider offices referring a patient to Brain Wellness Institute.

This form is for providers

Were you referred by a doctor? You do not need this form. Start here.

Prefer to call or fax?

Phone 949.743.1457, fax 949.274.8299.

Have these ready

Patient detailsName, date of birth, phone and address. For a minor, the parent or guardian's name.
InsuranceThe name of the insurance plan and the policy ID number.
Reason for referralWhat you would like us to evaluate or treat, plus any comments.
Your informationReferring provider, practice name and a phone number.

Please confirm the patient or family has been told about the referral. Fields marked with an asterisk are required.

Has the patient or family been told about this referral?*

Yes No

Patient Name*

Date of birth

If minor, parent / guardian name

Patient phone*

Address

City

State

Zip

Name of insurance

Policy ID #

Reason for referral*

Comments

Referring provider*

Practice name

Provider phone*

How did you hear about us?

If there is an immediate crisis or emergency, call 911.

Call 949.743.1457 and our team will help.