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)*

Psychiatry TreatmentPsychotherapy/Counseling ServicesBoth Psychiatry and Psychotherapy/Counseling Services

Patient Information
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 #