Primary_Care_Referral

Primary Care 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
Insurance:

BCBSAetnaCignaOxfordUHCTricare/HumanaOscarOther
Date Client started care with Referring Provider

MonthDayYear
Date
Date of last appointment

MonthDayYear
Date
Date of last in-person appointment

MonthDayYear
Date
Medical History:
Current Medications:
May send medical records to provide this information
Reason for Referral to Psychiatry at this time (please be specific):
Any Concerns for Safety:
Concerns or Population focus for us to be aware of:

Client is a mental health professionalHX of Psychiatric trauma or invalidatingLGBTQIAHX of CPTSD or TraumaHX medical TraumaTransgender or gender diverse or questioningFear or reluctance to take psychiatric medicationPoly/ENM/KinkTreatment resistant conditionSex workerSubstance abuse (we believe in harm reduction)Client has complex medical Hx, chronic pain or disabilityHX of Non-compliance
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.
Name of Referring Provider
Signature Referring Provider:

Clear
Practice Information
Best method of communication
Official Practice Email: admin@rainbowmentalhealthsvcs.com P: (224) 263-4671 http://www.rainbowmentalhealth.co/
Should be Empty:

Primary Care Referral For Psychiatric Services