New Patient Referral Form
Northwest ADHD Treatment Center only accepts referrals from medical and mental health care professionals.
***Please be aware that our waitlists may close. Check our website and consider wait times before referral submission***
https://nw-adhd.com/patient/ (scroll down the page to view waitlist times)
Waitlist Information
The following questions will be used to determine if our waitlists are presently open or closed for the referral you would like to submit. If the waitlist is closed, please check our website for updates.
Referral Category
*
Adult Commercial Insurance
Pediatric Commercial Insurance
Adult Medicaid Insurance
Pediatric Medicaid Insurance
Oregon State University Student
Self Pay
Referral Source
*
Primary Care
Behavioral Health Provider
Oregon State University - Student Health or Counseling Center
Other University Health or Counseling Center
Other
Patient Payment Category
*
Medicaid/ Oregon Health Plan
Commercial Insurance
Self - pay
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Based upon the information that you have entered, our waitlists are currently closed. Please check our website for updates.
Referring Provider Information
Referring Provider Name
*
First Name
Last Name
Provider Type
MD, DO, PMHNP, LPC, LCSW, LMFT, PCP, Psychologist, Counselor, Therapist, Etc.
Referring Provider Practice Name
*
Referring Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Provider Fax Number
Please enter a valid fax number.
Format: (000) 000-0000.
Referring Provider's Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Patient Information
Patient's Name
*
First Name
Last Name
Does the patient require interpretation services?
*
Please Select
Yes
No
Unsure
If interpretation services are needed, what is the Patient's primary language?
Patient's Date of Birth
*
-
Month
-
Day
Year
Patient's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Email
example@example.com
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Expand to add a Patient Guardian/ Authorized Representative
Patient's Guardian/ Authorized Representative Information
The following section only needs to be completed if someone other than the patient has legal authority to schedule appointments and make care decisions about the patient. This includes parents if a patient is a minor.
Patient's Guardian/ Representative Name
First Name
Last Name
Relationship to Patient
Parent, Legal Guardian, Caregiver, Etc.
Patient Guardian/ Representative's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Guardian/ Representative's E-mail
example@example.com
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Patient Insurance Information
Patient's Insurance Carrier
*
Oregon Health Plan, Medicaid, BCBS, Providence, United, MODA, Aetna, First Choice, Pacific Source, Beacon, MHN, Optum, Etc.
Patient's Insurance ID Number
*
Subscriber's Name
*
First Name
Last Name
Subscriber's Date of Birth
-
Month
-
Day
Year
Date
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Referral Information
What are you referring your patient for?
*
Evaluation for Attention Related Concerns Only
Attention Related Concern Evaluation and Treatment if Recommended (may include psychotherapy, medication management, and/or group treatment)
Group Treatment Only - Group treatment only requires the involvement of a mental health professional outside of Northwest ADHD Treatment Center to be responsible for the patient's ongoing mental health care
Patient Service Location Preference
*
Downtown Portland - 1201 SW 12th Ave, Suite 224Portland, OR 97205
East Portland - 13908 SE Stark, Suite A, Portland, OR 97233
West Portland - 12570 SW 69th Ave, Suite 200, Portland, OR 97223
Corvallis, OR
Virtual Appointments Preferred
Unsure
What are the patient's mental health diagnoses?
*
Please be inclusive.
Has the patient been diagnosed with an eating disorder?
*
What other clinically relevant information would you like to share?
Please include your rationale for referral, as well as any any physical, mental health, or substance use related conditions or symptoms that you believe may be impacting your patient's attention.
HIPAA Compliant Secure File Upload: Medical & Mental Health Records
*
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