Psychiatric Medication | Psychotherapy | Hypnotherapy | Marriage Counseling | Family Therapy

+1 (973) 600-5465

info@123psychiatry.com

Facebook

How it Works
Online Services
In-Person Services
Our Team
Contact Us
Book an Appointment

Referrals

Refer your client to 123 Psychiatry now

Connect your client to the care they need with our simple referral form.

OUR COMPREHENSIVE PROGRAM OFFERS:

Individual, group, and family therapy sessions several times per week
100% virtual access with flexible scheduling options
Covered by most insurance plans, including Medicaid and commercial providers

Have questions before referring? Contact our team — we’re here to help. +1 (973) 600-5465

123 Psychiatry Professional Referral Form

Please use this form to provide information on the patient you are referring to 123 Psychiatry. Our goal is to make this process as simple as possible.

Step 1 of 3

33%

Your first name(Required)

Your last name(Required)

Is this your first time referring to 123 Psychiatry?

Yes

Your state(Required)

Your organization(Required)

Your role (optional)

Your email(Required)

Your phone number(Required)

Patient's first name(Required)

Patient's last name(Required)

Patient's state(Required)

Patient's city (optional)

Patient's zip code(Required)

Patient's date of birth(Required)

Is there anything else you would like us to know about this patient that would help in ensuring a timely admissions process and effective care delivery? (optional)

Whose contact information are you providing?(Required)

Patient

Guardian

Who should 123 Psychiatry reach out to?

Client/Guardian

Referent (myself)

Both Referent (myself) and Client

Patient's phone number(Required)

Patient's email (optional)

Guardian's first name(Required)

Guardian's relationship to the patient(Required)

Guardian's phone number(Required)

Guardian's email (optional)

What type of insurance does your patient have?(Required)

Commercial/Private

Medicaid

Other

I don’t know

Would you like to provide additional patient insurance information?

Yes

Name of insurance carrier

Patient's Member ID

Group Number

Any other additional thoughts, questions or feedback for the 123 Psychiatry team?

PHONE:

+1 (973) 600-5465

EMAIL:

info@123psychiatry.com

Quick Links

How It Works

Online Services

In-Person Services

Our Team

Services

Psychiatric Medication

Psychotherapy

Hypnotherapy

Marriage Counseling

Family Therapy

Working Hours

Weekdays: 8:00am – 8:00pm
Saturday: 9:00am – 5:00pm
Sunday: Closed
By appointment only

Notice of Privacy Practices