Submit a Consultation Request

BHIPP Request Form

Please use this form to submit a request for resources and/or a consultation with a psychiatrist. *indicates a required field

Provider Information

Provider Name*(Required)

First Last

Degree*(Required)

Specialty

Practice Name*(Required)

Phone number*(Required)

Extension

Fax number

Email*(Required)

What type of request are you submitting?*(Required)

Patient Information

Please do not include any protected health information (PHI)

Patient Age

Patient Gender

Patient Race/Ethnicity

Trauma History

Type of Trauma

Patient Current Mental Health Diagnoses

Patient Presenting Concerns

Please share any mental health services the patient has previously engaged with:

Please share any mental health services the patient currently receives:

(including, but not limited to: IEP, 504 Plan, ABA therapy, OT, etc.)

Please describe the resources you need for your patient:

Does the patient have a history of visiting an ED for a mental health emergency?

Does the patient have a history of inpatient treatment for a mental health concern?

Describe any mental health services the patient currently receives:

Describe the results of any screening tools that have been completed:

(e.g. GAD-7 or PHQ-9)

What medications/dosages has the patient taken in the past for mental health concerns?

What medications/dosages does the patient currently take for mental health concerns?

Patient's Insurance(Required)

Patient's Zip Code(Required)

What would you like to discuss during your phone consultation?*(Required)

Schedule a Call

When should we call you?

Our team is availalbe M-F, 9am – 5pm

Date

Time

Alternate Date

Alternate Time

Anything else we should know?

Contact BHIPP

How can we help you?

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Schedule a phone consultation with our child mental health specialists when it’s convenient for you.

BHIPP Request Form

Provider Information

Patient Information

Schedule a Call

Contact BHIPP