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 *:
Notes:
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





close menu
Learn More