Referral Form
This form is intended only for clinical referrals. To submit a self-referral or are requesting an appointment on behalf of a family member or friend, please go to trianglemh.com/portal and click "Request an appointment." If you have questions about your referral, please email info@trianglemh.com. If this is an urgent request, please call (919) 450-8058
Referring Provider Information
Referring Provider Name
*
First Name
Last Name
Referring Practice Name:
Referring Provider Phone Number
*
Please enter a valid phone number.
Referring Provider Email Address
example@example.com
Patient Information
Patient Name
*
Patient First Name
Patient Middle Name
Patient Last Name
Date of Birth
*
-
Month
-
Day
Year
Patient DOB
Patient Phone Number
*
Please enter a valid phone number.
Patient Email Address
example@example.com
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Has the patient been made aware of this referral yet?
Yes
No
Patient Insurance Information
Insurance Company Name
Subscriber Name and DOB if different that patient name above
Insurance Policy ID Number
Insurance Group Number
Upload Insurance Card (Front)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload Insurance Card (Back)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Other insurance details (if needed)
Reason for referral
Please check all that apply:
Medication Management
TMS
Spravato / Ketamine
Legal
Other
Reason for Referral Details:
*
Other information as needed
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: