Behavioral Health Provider/Professional Referral Form

Behavioral Health Provider/Professional Referral Form

This form is intended for use by medical providers and personnel at Community Based Organizations as well as Criminal Justice Agencies referring an individual to Bleuler Psychotherapy Center. It ensures a seamless transition of care and facilitates communication between providers.
Instructions: Please complete this form with as much detail as possible. Accurate and thorough information will help us provide the best possible care.
Referral source information:
Name *

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Referral source agency information:
Please provide the information below for the individual you are referring.
Name*

First NameLast Name
Email
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Individual's primary language*
Date of birth*

MonthDayYear
Age
Individual's gender

MaleFemalePrefer not to sayOther
Address

Street Address

Street Address Line 2

CityState

Zip Code
Individual's insurance information:
Is the individual aware of this referral?*

YesNo
Please explain why the individual is not aware of this referral
Parent/Guardian Name (patient is a minor)*

First NameLast NameRelationship
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Platform for Treatment:

Virtual / TelehealthIn PersonNo PreferenceUnknown
Please provide a detailed description of the patient's current issues or symptoms that have led to this referral. Include any relevant diagnoses, behavioral concerns, or other significant factors contributing to the need for services at Bleuler Psychotherapy Center:
Has the individual had any prior outpatient mental health treatment?*

YesNoUnknown
Prior outpatient mental health treatment history
Has the individual had any psychiatric hospitalizations?*

YesNoUnknown
How many psychiatric hospitalizations in the last two years?
Is the individual currently being prescribed any psychotropic medication?*

YesNoUnknown
Current psychotropic medications
Date

MonthDayYear
Upload a copy of insurance card

Cancelof
Upload a copy of individual's ID

Cancelof
Upload any relevant clinical documentation

List of medications, prior therapy record, etc.
Cancelof
Please verify that you are human*
Should be Empty:

Behavioral Health Provider/Professional Referral Form

Referral source information:

Please provide the information below for the individual you are referring.