Provider Referral Form

Convenient, Comprehensive Mental Healthcare Tailored to Your Lifestyle
New Patient Referral Form

Thank you for entrusting us with your client/patient. Upon submission of this form, a staff member will contact the patient within 48 business hours. A patient in active crisis should NOT be referred to Modern Psychiatry. Call 911 or send patient to nearest emergency room.
Patient State of Residence
Modern Psychiatry is not currently licensed in the state that your patient resides in. Please leave us the state that you are trying to refer a patient from so we can better assist you in the future.
Insurance Provider
Service(s) the patient is seeking
Service(s) that patient is seeking: (OLD)
- Patient Name
  
  First NameLast Name
- Patient Date of Birth
  
  MonthDayYear
  Date
- Patient's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Patient Phone #
- Patient Email Address
  example@example.com
- Responsible Party
  
  (For patients under 18 years of age or adults with designated guardian/POA)
- Name
  
  First NameLast Name
- Relationship to Patient
- If other, please specify
- Responsible Party Phone #
- Referring Provider Name
- Title/Role
- Phone # of Referring Provider/Organization
- Reason patient is seeking mental health treatment. Include any current/past diagnoses. If patient is being referred by a hospital/PESS, please provide reason for admission/PESS involvement.
- Upload supporting documents (ROI, Demographic/Facesheet, Medication List, Progress Notes etc).
  
  Browse Files
  
  Cancelof
- Authorization & Acknowledgement
Should be Empty:

New Patient Referral Form

Responsible Party