referral form
Thank you for trusting Stacey Collins Nutrition with your patient’s care.
Your partnership helps us provide personalized, compassionate nutrition support for those living with Crohn’s disease, ulcerative colitis, or microscopic colitis.
Please complete the referral form below, including the patient’s name and email, and Stacey will connect with them directly to begin care.
Together, we can help them discover a more peaceful and nourishing way to support their health.
REFERRAL FORM
Here’s how it works:
Fill out the form, and someone from Stacey Collins Nutrition will be in touch within 3 business days to schedule an initial nutrition consultation with your patient.
Stacey will meet with your patient to listen to their nutrition concerns. This nutrition screening call is free of charge and allows your patient to make an informed decision on whether they would like to consent to continued nutrition care or not.
Nutrition care commences! For the next 3-6 months, your patient will work with Stacey to ensure their goals are met with nutrition counseling.
FREQUENTLY ASKED QUESTIONS
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No. We are a private pay practice. Patients are responsible for payment at the time of service, though we can provide a superbill for potential out-of-network reimbursement.
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We provide virtual nutrition care for patients with Crohn’s disease, ulcerative colitis, indeterminate colitis, microscopic colitis, or those who have undergone IBD-related surgeries such as J-pouch or ostomy procedures.
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Not required, but strongly preferred. Access to relevant medical history, recent labs, and clinical notes allows us to better support your patient’s care plan and make informed recommendations from the start.
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Yes. All information submitted through this form is encrypted and handled in accordance with HIPAA privacy and security standards.
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Once we receive your referral, our office will contact your patient directly, typically within 1–2 business days, to schedule their initial consultation.
If additional information is needed, we will reach out to your office to coordinate. You are welcome to follow up at any time for updates on your patient’s progress.