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*:

Notes:

Primary Insurance Type*:

Primary Insurance Carrier*:

Member ID*:

Group ID:

Policy Holder Name*:

Services Seeking*:

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

Refer a Patient (SANDBOX) - Brave Health