Refer a Patient - Brave Health

Refer a Patient

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 confirm that I have discussed Brave Health’s services with the individual listed above and have received their permission for Brave Health to outreach, including via electronic channels, and 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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