Consultation Request Form

As the requesting provider, please complete this form to the best of your ability. The more information we have about your request and concerns, the best we will be able to assist you.

Once the form is completed, a MPBHP behavioral health professional team member will be assigned to review the request and will reach out to you to complete the request.

Current Information
Patient Details
General Information
Complete

* = Required

Contact Date *

Contact Time *

Provider Name *

Provider Type *

If 'Other', please specify

Are you affiliated with any of the following: *

Practice Name *

Email Address *

Telephone Number *

Best Time to Call Back *

Best Contact Method *

Provider enrolled in BPBHP? *

Referral from another agency? (If Yes, please specify) *

Reason for Consultation *

Type of Consultation (check all that apply) *

Psychiatric Consultation

Care Coordination

Both

Other

If 'Other', please specify