Quick Admit Form

Refer a Patient to a Higher Level of Care

Thank you for considering Eating Recovery Center or Pathlight Mood & Anxiety Center as a treatment resource for your patient requiring a higher level of eating disorder care.

Our admissions process is designed with referring professionals in mind, and involves thorough assessment and information-sharing to ensure a holistic picture of the patient’s medical, psychological and social status. Our team involves you throughout the treatment process so you become educated, focused and knowledgeable about how to treat this illness and support the recovery of patients and families struggling with an eating disorder or mood, anxiety or trauma-related disorder.

You have three ways to make a referral

Contact our master’s level Clinical Assessment staff at 877-711-1878
Email us at info@e rcpathlight.com
Fax your patient's information to 425-974-1530
Or, if you are a referring provider, fill out the form below.

Our is Clinical Assessment Team is available to answer any of your questions about the referral process, treatment programs and aftercare planning. Additionally, we invite you to click here to review Frequently Asked Questions regarding our admissions process and insurance contracts.

Patient Information

First Name

Last Name

Date of Birth

Enter date in the YYYY-MM-DD fomat.

Phone

Race

Relationship status

Disabilities

Religion/Spiritual Orientation

Employment status

Yes

Unsure

Highest Education

Military service

Yes

Unsure

Guardian Information

First Name

Last Name

Phone

Relationship to Patient

Insurance Information

Name of Insurer

Insurance Contact Phone

ID/Account Number

Group Number/Account Number

Name of Policy Holder

Relationship to Patient

Policyholder Date of Birth

Enter date in the YYYY-MM-DD fomat.

Name of Employer

Treatment Team Information

Therapist Name

Dietitian

Psychiatrist

Primary Care Physician

Provider Assessment

Height

Weight

Diagnosis

Diagnosis Notes

Treatment History

Other Medical Issues

Current Medications

Known Food Allergies

Known Medication Allergies

Patient Strengths

Preliminary Treatment Goals

Submitting Provider Information

First Name

Last Name

Phone

Employer/Organization