Therapist 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
Insurance:
Type a question

BCBSAetnaCignaOscarOxfordUHCTricare/HumanaOther
Summary of Current Treatment Length of treatment
Beginning date

MonthDayYear
Date
End date

MonthDayYear
Date
Frequency of appointments
Focus of current work with client (please be specific):
Reason for referral:

Client RequestTherapist Recommended
Reason for Referral to Psychiatry at this time 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 professionalLGBTQIA+Transgender or gender diverse or questioningPoly/ENM/KinkSex WorkerClient has complex medical Hx, chronic pain or disabilityHX of Medical TraumaHX of Psychiatric trauma or invalidatingHX of CPTSD or TraumaFear or reluctance to take psychiatric medicationHX of Non-complianceTreatment resistant conditionSubstance abuse (we believe in harm reduction)
Additional Information Relevant to Clients care
Thank you for this referral. Please submit on our website, 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.
Signature of Referring Provider

Clear
Name of Referring Provider
Practice Information
Best method of communication
File Upload

Medical Records and Release of Information
Cancelof
Email: admin@rainbowmentalhealth.co www.rainbowmentalhealth.co Phone: (224) 263-4671 Fax: (224) 346-6471
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Therapist Referral For Psychiatric Services

Insurance:

Email: admin@rainbowmentalhealth.co www.rainbowmentalhealth.co Phone: (224) 263-4671 Fax: (224) 346-6471