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For Providers

Contact Us:

For Providers

Please complete this Patient Referral Form (below). 

For TMS patient referrals, please fill out our TMS Referral Form and either email it to us or fax it to 973-790-0671.

Thank you for allowing us to assist in the care of your patient. Please fill out the form below or print the above form and fax it to us.

Patient Name*

Patient Date of Birth

Patient Phone Number

Primary Diagnosis

Referring Provider

Provider's Specialty

Provider's Address

Provider's Email*

Provider Phone Number*

Provider Fax Number

Reason for Referral

Wayne Behavioral Service | 401 Hamburg Turnpike, Wayne, NJ 07470 | Phone: 973-790-9222

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