Clinician Referral Form
Patient Demographic Information
Please enter patient information below
Patient name
First Name
Last Name
Patient date of birth
-
Month
-
Day
Year
Date
Marital Status
Single
Married
Divorced
Widowed
Veteran?
Yes
No
Current Housing Type (e.g. Group Home)
Potential transportation Issues, please explain or N/A
Potential communication and technology use issues please explain or N/A. (E.g., patient uses teletype, cannot speak, sign language only, does not have a smart phone for telehealth/teletherapy, needs an interpreter, needs outside help to set up appointments etc.)
Patient address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home phone
Please enter a valid phone number.
Cell phone
Please enter a valid phone number.
Patient email [portal enrollment invitation will be sent to patient for secure messaging and appointments]
example@example.com
Patient Insurance, Primary Care, and Case Management
Social Security Number
Type of Insurance. [check all that apply]
Uninsured
Medicare/Medicaid
Private Insurance
Primary Care Physician
First Name
Last Name
Primary Care phone
Please enter a valid phone number.
Case Manager [leave empty if not applicable]
First Name
Last Name
Case Manager Phone
Please enter a valid phone number.
Case Management Agency
Services that case manager provides for patient
Patient Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship to Patient
Referring Clinician Information
Referred by
Referring Clinician Name
First Name
Last Name
Role (PCP, Case Manager, Psychiatric Prescriber etc.)
Agency/Clinic Name
Referring Clinician Phone
Please enter a valid phone number.
Referring Clinician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Clinician/Office Email
example@example.com
Patient Clinical Information
Reason for referral
When did the patient begin care with your office?
-
Month
-
Day
Year
Date
List of current psychiatric diagnoses
Is this patient receiving pharmacological treatment for the psychiatric diagnoses listed above?
Yes
No
List of all current medications and treatments or N/A
Is your office prescribing the patient's psychiatric treatment?
Yes
No
If "No" please provide the name and telephone number of the prescriber.
Prescriber name and contact phone.
Describe current psychiatric symptoms
Patient currently has suicidal thoughts?
Yes
No
Please explain suicidal thoughts.
Patient currently has homicidal thoughts?
Yes
No
Please explain homicidal thoughts?
Relevant medical diagnoses
Relevant social factors
Additional information
Past Psychiatric History and Treatment
History of violence?
Yes
No
If yes, please explain history of violence? or N/A
History of suicide attempts?
Yes
No
If yes, please explain history of suicide attempts? or N/A
History of past psychiatric hospitalizations?
Yes
No
If yes, please explain the history of past psychiatric hospitalizations? or N/A
Does your office have a signed release for Dr. Jean Metivier to speak with your office regarding this referral, records, and continuing treatment for the referred patient?
Yes
No
Copy of release from your office to communicate with Dr. Jean Metivier.
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