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Refer a Patient

If you feel your patient could benefit from Telehealth Outpatient Mental Health Treatment, please complete the information below.

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Client Information

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Referrer Information

By Submitting this form, I confirm that I have discussed BackPack services with the individual listed above and have their permission for Backpack Healthcare to reach out to them, via electronic channels, and I understand that BackPack is a telehealth therapy provider.