Referral for Behavioral Health Services By Primary Care Doctor
Thank you for trusting Pats Consultants for helping your client with their behavioral health needs. We would like to let you know that we will do our best to provide the best care possible as well as giving you information about their progress in treatment so that we can work collaboratively in their treatment.
Clients Information
Date:
-
Month
-
Day
Year
Date
Name:
First Name
Last Name
SS #:
DOB:
-
Month
-
Day
Year
Date
Age:
Gender:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number:
-
Area Code
Telephone Number
Reason for Referral:
Back
Next
Insurance Information
Name of Insurance:
Insurance Member Number:
Group Number:
Referral Information
Referral Source:
Telephone Number:
-
Area Code
Telephone Number
Name of Physician or Pediatrician treating client:
Ex: Dr. Patz
How long have you been seeing this client:
Ex: 6 months
What is the best way we can contact you to provide you with treatment progress information?
Is the client on any medication at this time?
If yes, what is the name of the medication?
Your Email address:
Telephone Number:
-
Area Code
Telephone Number
Please email this form to: appointment@patsconsultants.com
PO Box 8070, Tampa, FL 33674-8070 | PHONE: 888-666-3089 | FAX: 888-666-9870
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