Alleviant Provider Referral Form

Quick, Secure, and Collaborative Patient Referrals

How to Refer a Patient to Alleviant

At Alleviant Integrated Mental Health, we’re honored to partner with physicians, therapists, psychiatric providers, and other healthcare professionals to provide comprehensive, compassionate, and data-driven psychiatric care.

Our referral process is fast, secure, and designed to ensure seamless coordination between your practice and ours — with clear communication and timely access to care.

1. Download and Fax

STEPS:

  1. Download the Referral Form and complete all required fields.

  2. Fax the completed form to (833) 974-2069.

  3. Alternatively, email the form to newpatients@alleviant.com.

2. Fill Out the HIPAA-Compliant Form

STEPS:

  1. Complete the HIPAA-secure referral form below.

  2. Upload any relevant documents (clinic notes, med list, insurance info, etc.)

  3. Our intake team will reach out to the patient within 1 business day to begin the scheduling process.

  • All new patients seen within 7 days

  • Closed-loop communication with your office

  • Full-spectrum outpatient psychiatry under one roof

A referral form from Alleviant Integrated Mental Health requiring patient information such as name, date of birth, contact details, insurance, referral diagnosis, and provider details. The form also includes sections for location preference and services such as psychiatric evaluation, medication management, and therapy. Contact info for phone, fax, and email is provided at the top.

We Accept Referrals For Comprehensive Psychiatric Care

When you refer a patient to Alleviant, you’re referring them for comprehensive psychiatric evaluation and care. This includes:

  • Psychiatric assessment

  • Medication management (if appropriate)

  • Therapy and counseling

  • Health coaching

  • Spectral EEG brain mapping

  • Other advanced treatments (as clinically indicated)

We will always perform our own diagnostic intake evaluation with every patient, ensuring a full understanding of their condition and a clear clinical record in our EMR.

 

If You Are a Psychiatric Provider (MD, DO, PMHNP):

You may specify a treatment referral for:

  • TMS (Transcranial Magnetic Stimulation)

  • NeuroSync™ (Personalized rTMS)

  • Spravato®

  • Spectral EEG (sEEG)

However, we will still complete a full intake to ensure appropriateness and clinical alignment with Alleviant protocols.

For any questions or additional assistance, please contact us at (866) 951-4325. We look forward to working together to support the mental health and well-being of our shared patients.

Note: All patient information is handled in compliance with HIPAA regulations to ensure confidentiality and privacy.

Why Refer to Alleviant?

• Care across the lifespan (children, teens, adults, seniors)

• Data-driven treatment planning through spectral EEG

• Mission-driven, provider-led leadership

Thank You for Your Referral!

We appreciate your trust in Alleviant. Please note that our team makes up to 10 contact attempts with each referred patient before a referral is closed.

Occasionally, we receive feedback that a patient was not contacted. However, all inbound and outbound calls are recorded, and we thoroughly investigate every concern. In most cases, our records confirm that multiple call attempts were made, but the patient did not answer or return our calls.

We are committed to transparency and will always share the outcome of our investigation with you, so you have the full context regarding your patient’s referral status.