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Conditions
Depression
Anxiety
PTSD
Autism
TBI and Concussion
Cognitive Decline
Sleep Disorders
Autism
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Provider Referrals
For provider use only, if you are a patient seeking care for yourself or a loved one, please visit our “Contact Us” page or email us at info@theinsyncbrain.com.
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Patient's Name
*
First
Last
Patient's Office Number
Patient's Chief Complaint
*
Example: Depression, Anxiety, PTSD, Autism, etc.
Patient's Email
*
Patient's Phone Number
*
Name of Referring Provider and Provider's Office
*
Referring Provider's Email
*
Referring Provider's Phone Number
*
Referring Provider's Fax Number
*
Notes for Office Staff
Submit
