PROVIDER REFERRALS

HavenNexus Referral Form

Refer a patient to HavenNexus Advanced Psychiatry & TMS. Please complete the information below so our clinical team can review the referral and coordinate next steps.

Referring Provider Information

Please provide the referring provider's information.

Name *

Practice *

Specialty

Phone *

Fax

Email *

Patient Information

Please enter the patient's contact information.

Patient Name *

Date of Birth *

Phone *

Requested Services

Select all services requested for this patient.

TMS Therapy Transcranial Magnetic Stimulation IV Ketamine Therapy Medically monitored IV treatment MAT Medication-Assisted Treatment Spravato® Therapy Esketamine therapy Medication Management Psychiatric medication management

Patient Insurance Information

Please provide the patient's current insurance information.

Insurance Company / Plan Name

Member ID / Policy ID

Group Number

Referral Urgency

Please indicate the urgency of this referral.

Routine Standard referral review Urgent Priority clinical review requested

If urgent, please tell us why:

Additional Information for Our Clinical Team

Please provide any additional information that may help us evaluate and schedule this patient.