Referral to THERAPY Services
to be completed by referring CBI clinician / prescriber
Patient ID
*
Date of Referral
*
-
Month
-
Day
Year
Date
Referring Provider Name:
*
Email
*
example@example.com
Patient's primary DSM-V diagnosis / diagnoses:
*
Have you already coordinated this referral to another CBI clinician?
*
Yes
No
Name of Clinician:
In the event we do not have a licensed therapist available, a pre-licensed therapist or intern may be offered to the client for a self-pay rate.
*
I understand and my client is open to self-pay clinicians
I understand and my client would prefer a licensed clinician only
My client would be a good fit for weekly pro-bono services with a master's level intern if available
Most availability for client appointments is during daytime hours. Please be aware that evening or weekend appointments with a licensed clinician are extremely rare. Occasional evening or weekend appointments are available with self-pay clinicians (pre-licensed therapists or interns)
*
I understand
Additional Notes (reason for referral, therapy needs, patient preferences, treatment approach, etc.):
Additional Screening Questions
Please check all that apply:
*
Past/Active Psychosis or Mania
Past Alcohol/Substance abuse
Present Alcohol/Substance abuse
Present marijuana use for medical reasons
Present marijuana use for non-medical reasons
Past marijuana use
Current Eating Disorder diagnosis
Past Eating Disorder history
Medical complexities
None of the above
Are you considering a higher level of care for this patient?
*
No
Yes
Are there any safety-related concerns for this patient?
*
No
Yes
Please elaborate:
Clinician Signature
Continue
Continue
Should be Empty: