Therapy_Referral

Therapist Referral For Psychiatric Services
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. We may 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
Summary Of Current Treatment:
Beginning date

MonthDayYear
Date
End date

MonthDayYear
Date
Frequency of appointments
Focus of current work with client (please be specific)
Reason For Referral:
Type a question

Client RequestTherapist Recommendation
Reason for Referral (please be specific):
Any concerns for safety, if yes do they have a safety plan in place:
Your Clinical Impressions, Insights and Observations:
Concerns or Population focus for us to be aware of:

Client is a mental health professionalHX of Psychiatric trauma or invalidatingFear or reluctance to take psychiatric medicationHX of CPTSD or TraumaLGBTQIATransgender or gender diverse or questioningPoly/ENM/KinkSex workerHX of Non-complianceTreatment resistant conditionClient has complex medical Hx, chronic pain or disabilitySubstance abuse (we believe in harm reduction)Other
Additional Information Relevant to Clients Care:
Thank you for this referral. Please fax or email this form to us, along with a current release of information, and any additional relevant treatment records to our clinic.

Additionally, this form can be completed electronically on our website. Feel free to reach out to the clinic if you would like to schedule a phone consolation to discuss this client.
Name of Referring Provider:
Signature of Referring Provider:

Clear
Practice Information:
Best method of communication:
Official Practice Email: admin@rainbowmentalhealth.co

P: (224) 263-4671

www.rainbowmentalhealth.co
Insurance

BCBSAetnaCignaOxfordUHCTricare/HumanaOscarOther
Should be Empty:

Therapist Referral For Psychiatric Services

Summary Of Current Treatment:

Reason For Referral: