Refer To Us!
Tel. 631-881-4569 | Fax. 631-944-8000 | Email. dovepsychiatry624@gmail.com
Information about Person Completing Referral
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Would You Like To Build A Referral Business Relationship?
*
Yes
No
Best Way(s) To Communicate:
*
Phone Call
Text
Email
All Of the Above
Name Of Company:
*
Type Of Specialty:
*
Please Select
Therapist
Mental Health Counselor
Physician
Psychologist
Patient
Other
Is Individual aware of this Referral?
*
Yes
No
Anything Else You Want To Add (Please Do So Here)
*
If You Don't - Just Insert "N/A"
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Patient Gender
*
Male
Female
Other
Patient Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is The Patient Using Insurance?
*
Yes
No
Insurance Policy Name:
*
(Ex., Cigna, Aetna, 1199, etc.)
Insurance Policy ID Number:
*
(Ex. W24877-92874)
Who Is The Policy Holder?
*
Patient
Parent
Spouse
Name & DOB Of Policy Holder:
*
Reason for Referral:
*
If Nothing To Add - Just Insert "N/A"
Current Medications:
*
If You Don't Know - Just Insert "N/A"
Select all applicable challenges below for the Individual referred (check all that apply):
*
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Medication Education
Nutritional
Phobia/s
PRTF/Hospital Discharge
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Youth to Young Adult Transition
Other
Any Clinical Documents To Add?
*
Yes (1-2)
Yes (2-4)
No
Do You Have Pictures Of Their Insurance Card, Drivers License, And A Card To Save On File?
*
Yes
No
File Upload 1:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload 2:
*
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of
File Upload 3:
*
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of
File Upload 4:
*
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of
Insurance Card FRONT:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Insurance Card BACK:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Drivers License Of Patient (Or Form Of ID):
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Drivers License Of Policy Holder (Or Form Of ID):
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Card To Save On File:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: