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Are you a primary care physician or a psychiatric provider and looking to refer a patient for counseling services?

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Referring Provider's Name

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Fax #

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Follow Up Consultation

We at EPS believe that collaborating with our client's other providers enhances continuity of care and allows us to provide more comprehensive support. A collaboration would include a 15 minute billable case consultation every 90 days.

Please provide information for the referred patient:

First Name

Last Name

Email

Phone

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

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Insurance Provider