ADHD_Psych_Referral

Provider Referral For ADHD Evaluation

Instructions for referring professional:

Please complete all of the following sections as thoroughly as possible.

In addition to this Referral Form, we recommend sending a current release of information, and any treatment records you have that are relevant to this referral.

A release is helpful if we need to contact you to further discuss this client.

You may also reach out to the clinic to schedule a phone consultation.
Client Name
Date of Birth

MonthDayYear
Date
Beginning date

MonthDayYear
Date
Length of therapeutic relationship:
Frequency of appointments
Focus of current work with client, modalities of treatment:
Referall Information:
Reason for Referral to Psychiatry at this time (please be specific):
Specific observations or concerns for ADHD (if not listed above):
Assessment of Current Functioning:
Any concerns for safety, if yes do they have a safety plan in place:
Your Clinical Impressions, Insights and Observations
Your Clinical Impressions, Insights and Observations:
Additional Information Relevant to Clients care
Signature of Referring Provider

Clear
Name of Referring Provider
Practice Information
Best method of communication
Thank you for your referral and for taking the time to complete this form. Please fax, email or upload a current release of information, and any additional relevant treatment records to our clinic. Please feel free to reach out to the clinic if you would like to schedule a phone consolation to discuss this client.
Official Practice Email: admin@rainbowmentalhealth.co

P: (224) 263-4671 F: (224) 346-6471

http://www.rainbowmentalhealth.co/
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