ONLINE REFERRAL FORM

You may refer patients to my office by filling out the secure online Referral Form. After you have completed and signed the form, please make sure to press the SUBMIT button at the bottom to automatically send me the information.

This form is meant to help clinicians, clinics, hospitals, and case managers supporting patients to register for psychotherapy and to safely provide accurate medical information to inform treatment. This form also allows you to efficiently upload your communications release signed by the patient so that your office can communicate with Dr. Metivier about the patient’s ongoing care needs.

Clinician Referral Form

The security and privacy of patient data is one of my primary concerns and I have taken every precaution to protect it.

If you prefer to refer by FAX

Toll Free FAX (833)559-1088

Please include the disclosure release to share “between” Jean Metivier, PhD and the referring agency/clinician