Clinician Referral Form

Clinician Referral Form
Patient Demographic Information

Please enter patient information below
Patient name

First NameLast Name
Patient date of birth

MonthDayYear
Date
Marital Status
Veteran?
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

CityState / Province

Postal / Zip Code
Home phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell phone
Please enter a valid phone number.Format: (000) 000-0000.
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]
Primary Care Physician

First NameLast Name
Primary Care phone
Please enter a valid phone number.Format: (000) 000-0000.
Case Manager [leave empty if not applicable]

First NameLast Name
Case Manager Phone
Please enter a valid phone number.Format: (000) 000-0000.
Case Management Agency
Services that case manager provides for patient
Patient Emergency Contact
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Referring Clinician Information

Referred by
Referring Clinician Name

First NameLast Name
Role (PCP, Case Manager, Psychiatric Prescriber etc.)
Agency/Clinic Name
Referring Clinician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referring Clinician Address

Street Address

Street Address Line 2

CityState / 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?

MonthDayYear
Date
List of current psychiatric diagnoses
Is this patient receiving pharmacological treatment for the psychiatric diagnoses listed above?
List of all current medications and treatments or N/A
Is your office prescribing the patient's psychiatric treatment?
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?
Please explain suicidal thoughts.
Patient currently has homicidal thoughts?
Please explain homicidal thoughts?
Relevant medical diagnoses
Relevant social factors
Additional information
Past Psychiatric History and Treatment
History of violence?
If yes, please explain history of violence? or N/A
History of suicide attempts?
If yes, please explain history of suicide attempts? or N/A
History of past psychiatric hospitalizations?
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?
Copy of release from your office to communicate with Dr. Jean Metivier.

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Signature of referring clinician
Please verify that you are human
Should be Empty:

Clinician Referral Form

Patient Demographic Information

Patient Insurance, Primary Care, and Case Management

Patient Emergency Contact

Referring Clinician Information

Patient Clinical Information

Past Psychiatric History and Treatment