HCP Referral

Meru Health Referral Form

Patient Contact Information

Patient Name*

First Name

Last Name

Date of Birth*

State of residence*

Meru Health is currently operating in the US states listed here

Employer*

Email*

Preferred email to use with the Meru Health app - provide email that can be accessed from Mobile Phone

Mobile Phone Number*

Payer*

Insurance Number / Member ID *

Member ID including all letters and numbers * Example: ZCS1000888

Insurance Group Number *

Comments / Notes

Referring Healthcare Professional

Please provide the name and contact information for the treating provider who will receive treatment summaries from Meru Health.

Healthcare Professional Name*

First Name

Last Name

Phone

Email Address

Inclusion / Exclusion Criteria

Inclusion

Age 18 years or older
Smartphone with internet access (iPhone and Android)
Mild to severe depression and/or mild to severe anxiety and/or symptoms of burnout

Exclusion

Severe suicidal ideation with plan and/or intent
Any psychiatric disorder with distinct psychotic features (Schizophrenia, Major Depression with psychotic features, Bipolar I Disorder)

These criteria are meant as a guide. The Meru Health therapist will conduct a detailed phone screen to assess psychiatric symptoms and treatment program suitability.

This referral form complies with HIPAA.

If you have any questions, please contact our care team at support@meruhealth.com or via phone at (833) 940-1385.