NEHS – Website – Professional Referral

Please complete the form below with the information for the client/patient you are referring
Name*

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Phone*
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Email*
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Date of Birth*

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Date
About Me*
Nearest Clinic*
Insurance Plan
What is the best time of day to reach you or your client/patient?

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How can we help?
For those who are eligible, we offer FDA-approved alternative treatments for depression such as Transcranial Magnetic Stimulation and Spravato. Are you interested in learning more or would you like to recommend that your client/patient learn more about these alternative treatment options?*

YesNo
Referring Organization Name*
Referring Organization Contact Person
Referring Organization Phone
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Referring Organization Email
example@example.com
How did you hear about us?*
First time referring?*

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