Refer a Patient (SANDBOX) - Brave Health

Refer a Patient (SANDBOX)

Required Fields (*)

To refer a member to Brave, please fill out this secure form.

We’ll use the member’s information to outreach them, and your information to share progress updates.

Patient Information
First Name*:Last Name*:
Date of Birth MM/DD/YYYY*:Patient State*:
Mobile Number (###-###-####)*:Email Address*:

Referrer Information
Referring Contact Name*:Referring Contact Email*:
Primary Insurance Carrier*:Member ID*:
Group ID:Policy Holder Name*:

By Submitting this form, I understand that Brave is an outpatient virtual behavioral health provider. Brave can treat most mental health conditions, with the following exclusions:

Patients must be oriented to time and place and able to consent to their own treatment

  • Brave does not directly prescribe benzodiazepines or stimulants (but can coordinate with other prescribers who do)
  • Brave does not provide eating disorder treatment

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