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.
Service(s) that patient is seeking:
*
Psychiatry Treatment
Psychotherapy/Counseling Services
Both Psychiatry and Psychotherapy/Counseling Services
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
/
Month
/
Day
Year
Date
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone #
*
Patient Email Address
example@example.com
Name of Provider/Person Completing Form
*
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
Cancel
of
Responsible Party
(For patients under 18 years of age or adults with designated guardian/POA)
Name
First Name
Last Name
Relationship to Patient
Please Select
Mother
Father
Legal Guardian/POA
Other
If other, please specify
Responsible Party Phone #
Submit
Should be Empty: