Allied Psychophysiology Referral Form
This secure (256-bit SSL) online form streamlines the referral process and will help us schedule your patients to be seen more quickly. It is also part of our digital patient records initiative which results in a “greener” practice that uses less paper and efficiently processes patient records in a secure and environmentally friendly manner that helps reduce administrative overhead costs.
1. Referrer's Name: *
2. Referrer's (individual) NPI:
3. Referrer Email or Fax number (so we can send you a confirmation of referral): *
4. Patient's Name (last, first): *
5. Patient Phone Number, including area code: *
6. Patient Date of Birth: (MM DD YYYY) *
7. Patient's Insurance: We are in-network for Blue Cross Blue Cross (PPO plans), TRICARE, Medicare B, Cigna (PPO plans only). Note if patient is referred for biofeedback and neurofeedback: reimbursement policies vary, and not all services are covered. Please answer question 10: secondary insurance, if patient has more than one insurance.
  • Blue Cross Blue Shield
  • TRICARE
  • Medicare B
  • Cigna
  • Other insurance - out of network (list below)
  • No insurance (we offer sliding scale)
8. Other Insurance (out of network) Name:
9. Insured's ID Number:
10. Secondary Insurance Name and Policy ID:
11. Is patient's condition related to: *
  • Auto Accident
  • Employment
  • Other Accident
  • None of these
12. If you checked any of the above, provide the date of accident & the state in which it occurred.
13. Services requested: (check all that are relevant) *
  • ADHD simple assessment (IVA+, history & interview)
  • ADHD/LD/ASD complex assessment (IVA+, history & interview, QEEG-based neuro-metric analysis)
  • Adult Anxiety and Stress Management (biofeedback and/or psychotropic medication services for patients aged 18 and older)
  • Biofeedback for functional disorders
  • Biofeedback for headache management
  • Biofeedback for pain disorders
  • Brain Injury Assessment (IVA+, history & interview, QEEG-based neuro-metric analysis w/ neurologist review)General neuropsychiatric referral
  • Pediatric anxiety disorders (biofeedback – we do not medicate pediatric patients)
  • Psychotropic medication recommendations based on EEG (validated from age 6-90: generally considered experimental by insurance companies and reimbursed for treatment refractory patients only – medication taper usually required)
  • Neurofeedback (for ADHD, mTBI, depression)
  • Neurofeedback for other disorder
  • Supportive therapy/ case management for major medical condition (note below)
14. Notes or clarification to items on question 13 - services requested.
15. Optional file (up to 3 MB) upload
16. Preferred Method of Consultation *
  • Call me to schedule a case consult
  • Please send me a summary of findings
  • Please send me all records and reports at the completion of treatment